Local anaesthetic systemic toxicity can present with perioral tingling, tinnitus, agitation or a metallic taste, but often begins with a seizure or arrhythmia with no warning. It may occur up to an hour after injection, and with fascial plane blocks using large volumes.
Stop injecting, call for help, manage the airway and give 20% lipid emulsion early. Benzodiazepines treat seizures; avoid large doses of propofol in an unstable patient. If cardiac arrest occurs, use smaller adrenaline doses and expect prolonged resuscitation.
- Keep 20% lipid emulsion and a printed protocol wherever blocks are performed.
- Give a lipid bolus of about 1.5 ml/kg over two to three minutes, then start an infusion, at the first serious sign.
- Calculate the maximum safe dose for every patient before the first injection, across all blocks.
- Monitor patients for at least 30 minutes after large-volume fascial plane blocks.
Why it matters
Toxicity can follow any large-volume block, and lipid works best when given early.
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