Local anaesthetic systemic toxicity can present as perioral tingling, tinnitus, agitation or seizures, or go straight to arrhythmia and cardiovascular collapse. It can occur up to an hour after a block.
Stop injecting, call for help, manage the airway and treat seizures with a benzodiazepine. Give 20% lipid emulsion early: a 1.5 mL/kg bolus over a minute, then an infusion of 15 mL/kg/h, repeating the bolus up to twice if needed. In cardiac arrest, use lower adrenaline doses and continue CPR, as recovery may take time.
- Calculate the maximum safe local anaesthetic dose by weight before every block
- Keep 20% lipid emulsion and a toxicity checklist wherever blocks are done
- Monitor patients for at least 30 minutes after a large-volume block
- Give a 1.5 mL/kg lipid bolus at the first sign of cardiovascular toxicity
- Continue resuscitation for longer than usual in local anaesthetic cardiac arrest
Why it matters
With more plane blocks using large volumes, toxicity is a real risk outside theatres.
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