Local Anesthetic Systemic Toxicity Caused by Non-Anesthesiologists: A Narrative Review of Case Reports

Abstract

Background: Local anesthetics are widely utilized by anesthesiologists and physicians to manage pain effectively. Local anesthetic systemic toxicity (LAST) is an infrequent occurrence that can lead to fatal outcomes. Although local anesthetics are commonly employed by nonanesthesiologists, a comprehensive analysis of case reports detailing LAST incidents caused by physicians other than anesthesiologists remains unknown. This review was performed to analyze case reports of LAST induced by non-anesthesiologists. Methods: Case reports regarding LAST induced by non-anesthesiologists were retrieved from PubMed using the following keywords: “bupivacaine toxicity,” “levobupivacaine toxicity,” “lidocaine toxicity,” “ropivacaine toxicity,” “tetracaine toxicity,” and “prilocaine toxicity” until December 31, 2023. A total of 53 case reports involving 59 patients were identified. Results: The distribution of local anesthetic use linked to LAST was as follows: lidocaine alone (59.33%), lidocaine plus prilocaine (11.86%), and bupivacaine or ropivacaine alone (10.17%). The predominant presumed cause of LAST was an overdose of local anesthetics (67.80% of all patients; lidocaine: 75% of local anesthetic overdoses), with or without accompanying patient’s risk factors. The primary routes of administration resulting in LAST were subcutaneous infiltration (38.98%) and topical application (35.59%). Common symptoms associated with LAST included central nervous system symptoms alone (50.85%) such as seizures, and combined central nervous and cardiovascular system symptoms (27.12%). Local anesthetics implicated in LAST were predominantly used for pain management during various procedures (71.19%) and for post-operative analgesia (11.86%). Of the patients experiencing LAST, 28.81% received lipid emulsion treatment in addition to supportive measures, achieving a full recovery rate of 100%. Conversely, 71.19% of the patients with LAST received only supportive treatment, leading to a full recovery rate of 73.81%. Conclusion: These findings suggest that subcutaneous infiltration or topical administration of lidocaine overdoses by non-anesthesiologists, particularly in patients with or without risk factors for LAST, significantly contributes to LAST. Preventive strategies, including education on maximum recommended doses of local anesthetics, identification of patient risk factors for LAST, utilization of ultrasound-guided nerve blocks, and ensuring the availability of lipid emulsion treatment, should be emphasized. Lipid emulsions ought to be readily accessible for the management of LAST in all locations where local anesthetics are used.