Header bg
  • Users Online: 181
  • Print this page
  • Email this page
Header bg

CASE REPORT Table of Contents  
Ahead of print publication
Successful resuscitation after cardiac arrest in a patient presenting with local anesthetic systemic toxicity

1 Department of Anaesthesiology and Critical Care, Military Hospital, Jaipur, Rajasthan, India
2 Department of Anaesthesiology and Critical Care, INHS Sanjivani, Kochi, Kerala, India

Click here for correspondence address and email

Date of Submission17-May-2020
Date of Decision17-Jun-2020
Date of Acceptance25-Jun-2020
Date of Web Publication28-Aug-2020


Local anesthetics are used frequently in health-care practice, being used by physicians, surgeons, and anesthesiologists; however, the local anesthesia systemic toxicity (LAST) is still not taken very seriously by the health-care workers (HCWs). LAST is an underreported complication, and many HCWs need to experience it firsthand to realize the criticality of the situation. The idea behind publishing this case report is to increase the awareness of complication called LAST and familiarize HCWs with the management guidelines.

Keywords: Cardiac arrest, local anesthesia bradycardia, resuscitation

How to cite this URL:
Sharma S, Bhardwaj G, Bhatnagar V. Successful resuscitation after cardiac arrest in a patient presenting with local anesthetic systemic toxicity. Bali J Anaesthesiol [Epub ahead of print] [cited 2021 Apr 22]. Available from: https://www.bjoaonline.com/preprintarticle.asp?id=293615

  Introduction Top

Local anesthetics (LA) are utilized frequently by various doctors in health-care settings. However, the reported incidence of Local anesthetic systemic toxicity (LAST) is estimated to be 0.03% (0.27 episodes/1000 peripheral nerve blocks).[1] Mörwald et al.[2] reported that the incidence of LAST is 1.8/1000 peripheral nerve blocks during joint replacement, which makes this rare event not “so rare.” LAST can turn out to be life-threatening, and it is advisable to be vigilant for its possibility in any patient who receives LA. We present a case which landed up with cardiac arrest after LA administration for sciatic nerve block for open reduction internal fixation (ORIF) of fracture medial malleolus of the right side.

  Case Report Top

A 72-year-old male patient with no significant past medical history was posted for ORIF due to fracture of the right medial malleolus. On preanesthetic checkup, his vitals were within normal limits, and his physical examination was essentially normal. The patient denied having any allergies and was accepted in the American Society of Anesthesiologists physical Grade II. The anesthetic plan was peripheral nerve stimulator (PNS)-guided right-sided sciatic nerve block and sedation. On the morning of the surgery, the patient was taken to the operating room (OR), and standard monitoring was applied. The classic posterior approach was taken to block the sciatic nerve (right side) using PNS. At a depth of 6 cm, the sciatic nerve was localized with the help of twitches at the calf and foot at a current of 0.5 mA, and a 25-ml solution (a mixture of 10-ml bupivacaine, 6-ml lignocaine, and 9-ml sterile water) was injected after negative aspiration. Immediately after LA administration, the patient experienced generalized tonic-clonic seizures (GTCS).

Suspecting LAST, an alarm was raised, and GTCS was managed with midazolam 2 mg, lorazepam 4 mg, and propofol 50 mg. The patient was intubated with 8.5-mm internal diameter cuffed Polyvinyl chloride endotracheal tube orally using atracurium 30 mg. Blood pressure was stable during the GTCS episode and post intubation. However, the heart rate started fluctuating in the range of 46–50/min, with electrocardiography showing sinus bradycardia. Atropine 0.6 mg was given twice to correct bradycardia. Twenty percent intralipid emulsion was given as 1.5 ml/kg bolus followed by infusion (0.25 ml/kg/min) as per the NYSORA and ASRA guidelines to manage LAST, and the patient was monitored in the OR.[3]

The patient's vitals remained stable for the next 30 min; arterial blood gas analysis was performed, and it confirmed pH, arterial oxygenation (PaO2), and arterial carbon dioxide (PaCO2) within normal limits. The decision to proceed with surgery was taken because this was a semi-emergency case. General anesthesia was maintained with oxygen: air: sevoflurane mixture to reach minimum alveolar concentration of 0.8–0.9, and paralysis was maintained with atracurium. Post-GTCS adverse events and their management are depicted in [Table 1].
Table 1: Postgeneralized tonic-clonic seizure adverse events and their management

Click here to view

The patient was electively ventilated overnight, maintained vitals throughout, and noradrenaline infusion was tapered. The next day, the patient was successfully weaned off and extubated after a thorough neurological, respiratory, and cardiac examination. The remaining hospitalization period remained uneventful, and the patient was discharged on the 8th postoperative day.

  Discussion Top

The central nervous system (CNS) and cardiovascular system (CVS) are most commonly involved in LAST. Mostly, the signs and symptoms developed on a mixture of LA used are a combination of CNS and CVS toxicity. However, isolated CVS and CNS toxicity may also be noted in a few cases. Cardiac toxicity associated with the overdose of intravascular injection of LA is characterized by hypotension, atrioventricular conduction delay, idioventricular rhythms, and eventual cardiovascular collapse.

Although all LA drugs potentially shorten the myocardial refractory period, bupivacaine avidly blocks the cardiac sodium channels, thereby making it most likely to precipitate malignant arrhythmias. As for toxicity with lignocaine, miscalculation of the dose, injection of the drug into a blood vessel, or repeated administration of therapeutic doses are the major causes of systemic toxicity.[3] Lignocaine works by binding voltage-gated sodium channels, thus inhibiting the propagation of action potential. The main target organs are CNS and CVS. Because the CNS is more sensitive to electrophysiological changes than the CVS, neurological symptoms such as dizziness, tinnitus, and peri-oral numbness usually precede cardiovascular manifestations during lignocaine systemic toxicity.[3] Cardiac instability is fatal, and to prevent mortality, lipid infusion is recommended.[3],[4],[5]

Vigilance is recommended – early recognition of symptoms to start management as soon as possible. Stop LA injection immediately, maintain airway with bag valve mask and endotracheal intubation, and, if required, administer 100% oxygen. Secure intravenous (IV) access, if not already secured; push IV fluids; and control seizures with lorazepam, midazolam or propofol or thiopentone. Monitor cardiac activity and initiate cardiopulmonary resuscitation if needed. Antiarrhythmics should be administered if required. Hypotension, if persists, needs to be treated with inotropes.

Blood samples should be collected and sent for analysis. Lipid emulsion needs to be administered simultaneously.

The American Society of Regional Anesthesia and Pain Medicine recommends an initial bolus of 1.5 mg/kg of 20% IV lipids (intralipids) followed by a continuous infusion of 0.25 mL/kg/min. If cardiac stability is not restored, then the infusion rate can be doubled to 0.5 mL/kg/min, and it is recommended to continue the infusion until cardiac stability is restored for at least 10 min.[3] Various mechanisms have been postulated on how lipid infusion works, but the most widely accepted is the “sink theory” by which lipids create a sink that extracts LA from plasma, making them unavailable for myocardial tissue.[4]

It is extremely important for all team members to be aware of the hazard known as LAS, be aware of the antidote and also where it is stored in the OR setup. A standard operating procedure or institutional guideline formulated and displayed at prominent places is also a great help in making health-care workers (HCWs) aware of this complication and its early management.

  Conclusion Top

The idea of presenting this case is to raise awareness regarding LAST in the HCWs, which, though considered rare, can turn out to be fatal and also to highlight the importance of extreme vigilance and the use of IV lipid infusion as the treatment of choice to reverse the symptoms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: Current perspectives. Local Reg Anesth 2018;11:35-44.  Back to cited text no. 1
Mörwald EE, Zubizarreta N, Cozowicz C, Poeran J, Memtsoudis SG. Incidence of local anesthetic systemic toxicity in orthopedic patients receiving peripheral nerve blocks. Reg Anesth Pain Med 2017;42:442-5.  Back to cited text no. 2
Neal JM, Barrington MJ, Fettiplace MR, Gitman M, Memtsoudis SG, Mörwald EE, et al. The Third American Society of Regional anesthesia and pain medicine practice advisory on local anesthetic systemic toxicity: Executive summary 2017. Reg Anesth Pain Med 2018;43:113-23.  Back to cited text no. 3
Ozcan MS, Weinberg G. Intravenous lipid emulsion for the treatment of drug toxicity. J Intensive Care Med 2014;29:59-70.  Back to cited text no. 4
Harvey M, Cave G, Chanwai G, Nicholson T. Successful resuscitation from bupivacaine-induced cardiovascular collapse with intravenous lipid emulsion following femoral nerve block in an emergency department. Emerg Med Australas 2011;23:209-14.  Back to cited text no. 5

Correspondence Address:
Vidhu Bhatnagar,
Department of Anaesthesiology and Critical Care, INHS Sanjivani, Naval Base, Kochi - 682 004, Kerala
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_82_20


  [Table 1]


   Ahead Of Print
 Article in PDF
     Search Pubmed for
    -  Sharma S
    -  Bhardwaj G
    -  Bhatnagar V

Case Report
Article Tables

 Article Access Statistics
    PDF Downloaded6    

Recommend this journal