Bio: Michael Fettiplace, MD, PhD, is an assistant professor at the University of Illinois of Chicago. His work focuses on the safe use of local anesthetics, including dosing strategies to reduce the risk of toxicity from local anesthetics and treatment strategies for local anesthetic systemic toxicity (LAST).  He has contributed to professional society recommendations about treatment of LAST from the American Society of Regional Anesthesia and the American Heart Association and his work underpins recommendations from other societies.

Abstract: Local anesthetic systemic toxicity (LAST) is a complication resulting from high blood levels of local anesthetics, leading to seizures, cardiac arrhythmias and death. Current treatment recommendations advise the use of intravenous lipid emulsion (ILE) as part of the treatment strategy1 primarily based on pre-clinical data2 and case reports. Clinical trials of ILE in LAST are considered unethical and unlikely to occur. However, mechanistic trials in humans3 support the pharmacokinetic benefit of ILE seen in animal models4. Additionally, randomized trials demonstrate ILE’s effectiveness in reversing toxidromes from organophosphate poisoning5 and poisoning from other agents5. Emerging data suggest that since the advent of ILE, bupivacaine-related poisonings have declined significantly. Uncertainties remain about the optimal ILE dosage, its role in treating toxicity from local anesthetics other than bupivacaine, and its use in non-local anesthetic poisoning. These items will be discussed.

References:

1. Neal JM, Barrington MJ, Fettiplace MR, et al.: The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity. Reg Anesth Pain Med 2018; 43:113–23

2. Fettiplace MR, McCabe DJ: Lipid emulsion improves survival in animal models of local anesthetic toxicity: a meta-analysis. Clin Toxicol (Phila) 2017; 55:617–23

3. Dureau P, Charbit B, Nicolas N, Benhamou D, Mazoit JX: Effect of intralipid® on the dose of ropivacaine or levobupivacaine tolerated by volunteers. Anesthesiology 2016; 125:474–83

4. Fettiplace MR, Weinberg G: Lipid emulsion for xenobiotic overdose: PRO. Br J Clin Pharmacol 2023; 89:1708–18

Yu S, Yu S, Zhang L, et al.: Efficacy and outcomes of lipid resuscitation on organophosphate poisoning patients: A systematic review and meta-analysis. American Journal of Emergency Medicine 2019; 37:1611–7