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Department discussion on LAST (Local Anesthetic Systemic Toxicity)

Presented by: Dr. Marisa Baorto

https://www.youtube.com/watch?v=b70Li9r3pL8

Local Anesthetic Systemic Toxicity (LAST) Revisited: A Paradigm in Evolution - Anesthesia Patient Safety Foundation (apsf.org)

Local Anesthetic Cardiac Toxicity can Present as Late-onset Hypotension, Bradycardia, and Asystole | Anesthesiology | American Society of Anesthesiologists (asahq.org)

Injection of bupivacaine Liposome must not occur within 20 min after the administration of non-bupivacaine local anesthetics, such as lidocaine, because it could cause the immediate release of bupivacaine from the liposome. If the liposomal bupivacaine is injected into the surgical site within 20 min of administration of another non-bupivacaine local anesthetic, the systemic absorption of local anesthetic increases. Bupivacaine HCl, when injected immediately before Exparel, may impact the pharmaco-kinetics of the drugs if the milligram dose of bupivacaine HCl solution exceeds 50% of the Exparel dose. The toxic effects of these drugs are additive.

Different strokes for different folks:

            Bupi- more likely to lead to ventricular dysrhythmias.

            Other locals- brady, hypotension, asystole or ventricular dysrhythmias

Thereafter, it became evident that bupivacaine differs from other local anesthetics in that it has a narrower margin between the dose or plasma concentration required to produce seizures as compared to those resulting in cardiovascular collapse. 4–6This accrues from the fact that supra convulsant doses of bupivacaine, but not lidocaine or mepivacaine, may induce lethal ventricular arrhythmias out of proportion to the drug's anesthetic potency. 4–6Two theories have been proposed to explain this phenomenon. First, both bupivacaine and lidocaine block cardiac sodium channels rapidly during systole; however, during diastole, bupivacaine dissociates off these channels at a much slower rate than lidocaine. 7As a result, at normal heart rates, diastolic time is sufficiently long for dissociation of lidocaine, but a bupivacaine block intensifies and depresses electrical conduction, causing reentrant type ventricular arrhythmias. Second, high blood concentrations of bupivacaine may cause a ventricular arrhythmia through a direct brainstem effect.”