Treatment of Local Anesthetic Toxicity

1. Get help. Ventilate with 100% oxygen. Alert nearest facility with cardiopulmonary bypass capability.
2. Resuscitation: airway/ventilatory support, chest compressions, etc. Avoid vasopressin, calcium channel blockers, β-blockers, or additional local anesthetic. Reduce epinephrine dosages. Prolonged effort may be required.
3. Seizure management: benzodiazepines preferred (eg, intravenous midazolam 0.1–0.2 mg/kg); avoid propofol if cardiovascular instability.
4. Administer 1.5 mL/kg 20% lipid emulsion over ∼1 minute to trap unbound amide local anesthetics. Repeat bolus once or twice for persistent cardiovascular collapse.
5. Initiate 20% lipid infusion (0.25 mL/kg per minute) until circulation is restored; double the infusion rate if blood pressure remains low. Continue infusion for at least 10 minutes after attaining circulatory stability. Recommended upper limit of ∼10 mL/kg.
6. A fluid bolus of 10–20 mL/kg balanced salt solution and an infusion of phenylephrine (0.1 μg/kg per minute to start) may be needed to correct peripheral vasodilation.