Suspect LAST
Signs/symptoms during or after local anesthetic administration
All Pathways
AnesthesiologyEmergency
Local Anesthetic Systemic Toxicity (LAST) Management (ASRA 2020)
Local Anesthetic Systemic Toxicity (LAST) Management (ASRA 2020): Suspect LAST → LAST Signs Present? → Call for Help & Get Lipid Emulsion → Airway Manag...
Pathway Overview
12 steps
Algorithm Steps
12 total
01Start 02Decision LAST Signs Present?
CNS and/or cardiovascular toxicity
- CNS EXCITATION: agitation, confusion, metallic taste, tinnitus, perioral numbness, seizures
- CNS DEPRESSION: drowsiness, obtundation, coma, respiratory arrest
- CV SIGNS: hypotension, bradycardia, arrhythmias, asystole
- Atypical presentations common - maintain high index of suspicion
03Action Call for Help & Get Lipid Emulsion
Immediate actions
- Stop injection of local anesthetic immediately
- Call for help
- Get LAST rescue kit (lipid emulsion 20%)
- Consider calling ACLS team
- Designate team leader
04Action Airway Management
Prevent hypoxia and acidosis which worsen toxicity
- 100% oxygen via mask or secure airway
- Ventilate if apneic
- Prevent aspiration
- Avoid hyperventilation (may worsen CNS toxicity)
05Decision Seizure Activity?
Treat seizures promptly to prevent acidosis
06Action Treat Seizures
Benzodiazepines preferred
- Midazolam 2-4 mg IV or
- Diazepam 5-10 mg IV or
- Lorazepam 2-4 mg IV
- Avoid large propofol doses (cardiac depression)
- If refractory: consider small propofol doses
- Succinylcholine stops motor activity but not CNS seizure
07Decision Cardiac Instability or Arrest?
Hypotension, arrhythmia, or cardiac arrest
08Action Lipid Emulsion 20% Therapy
CRITICAL: Start lipid even if stable but symptomatic
- BOLUS: 1.5 mL/kg over 1 minute (~100 mL for 70 kg)
- INFUSION: 0.25 mL/kg/min
- If unstable: repeat bolus 1-2 times at 3-5 min intervals
- Double infusion to 0.5 mL/kg/min if unstable
- Continue infusion ≥15 min after hemodynamic stability
- Maximum ~10-12 mL/kg in first 30 minutes
09Warning ⚠️ AVOID These Drugs
Contraindicated in LAST:
- Vasopressin
- Calcium channel blockers
- Beta-blockers
- Additional local anesthetics (e.g., lidocaine for arrhythmia)
- Large doses of propofol
10Action Monitoring & Post-Event
Observe for recurrence
- Monitor ≥4-6 hours after treatment
- Watch for recurrence (may occur for up to 2 hours)
- Report event to www.lipidrescue.org
- Obtain serum LA levels if available
- Document carefully for future care
11Outcome Patient Stabilized
Continue monitoring, document event
12Warning ⚠️ CARDIAC ARREST
Modified CPR + Lipid therapy
- Start CPR immediately
- Give lipid bolus AND infusion as above
- REDUCE epinephrine dose to <1 mcg/kg
- AVOID: vasopressin, calcium channel blockers, beta-blockers, lidocaine
- Consider prolonged resuscitation (>60 min) - lipid may delay recovery
- Consider ECMO/CPB if available
- Path rejoins step 08Shared downstream outcome
- Path rejoins step 07Shared downstream outcome
Guideline Source
American Society of Regional Anesthesia and Pain Medicine Local Anesthetic Systemic Toxicity Checklist: 2020 Version
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Lipid emulsion must be immediately available
- Does not cover delayed presentations
- Pediatric dosing may require adjustment
- May mask bupivacaine cardiotoxicity recovery
Applicable Regions
USEUglobal
EU: Compatible with ESRA recommendations
US: Based on ASRA 2020 guidelines
Version 1Next review: 2027-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Local Anesthetic Systemic Toxicity (LAST) Management (ASRA 2020)?
The Local Anesthetic Systemic Toxicity (LAST) Management (ASRA 2020) is a emergency clinical algorithm for Anesthesiology. It provides a structured decision tree to guide clinical decision-making, based on American Society of Regional Anesthesia and Pain Medicine Local Anesthetic Systemic Toxicity Checklist: 2020 Version.
What guideline is the Local Anesthetic Systemic Toxicity (LAST) Management (ASRA 2020) based on?
This algorithm is based on American Society of Regional Anesthesia and Pain Medicine Local Anesthetic Systemic Toxicity Checklist: 2020 Version (DOI: 10.1136/rapm-2020-101986).
What are the limitations of the Local Anesthetic Systemic Toxicity (LAST) Management (ASRA 2020)?
Known limitations include: Lipid emulsion must be immediately available; Does not cover delayed presentations; Pediatric dosing may require adjustment; May mask bupivacaine cardiotoxicity recovery. Individual patient factors may require deviation from these recommendations.
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