Guidelines for the Management of Severe Local Anaesthetic Toxicity

Signs of Severe Toxicity

  • Sudden loss of consciousness, with or without tonic-clonic convulsions
  • Cardiovascular collapse: sinus bradycardia, conduction blocks, asystole and ventricular tachyarrhythmias may all occur
  • Local anaesthetic (LA) toxicity may occur some time after the initial injection

Immediate Management

  • Stop injecting the LA
  • Call for help
  • Maintain the airway and, if necessary, secure it with a tracheal tube
  • Give 100% oxygen and ensure adequate lung ventilation (hyperventilation may help by increasing pH in the presence of metabolic acidosis)
  • Confirm or establish intravenous access
  • Control seizures: give a benzodiazepine, thiopental or propofol in small incremental doses
  • Assess cardiovascular status throughout

Management of a Cardiac Arrest

  • Start cardiopulmonary resuscitation (CPR) using standard protocols
  • Manage arrhythmias using the same protocols, recognizing that they may be very refractory to treatment
  • Prolonged resuscitation may be necessary; it may be appropriate to consider other options:
  • Consider the use of cardiopulmonary bypass if available
  • Consider treatment with lipid emulsion

IntraLipid® Therapy of Arrest (70kg)

  • Give an intravenous bolus injection of Intralipid® 20% 1.5 ml/kg over 1 min
  • Give a bolus of 100 ml
  • Continue CPR
  • Start an intravenous infusion of Intralipid® 20% at 0.25 ml/kg/min
  • Give at a rate of 400 ml over 20 min
  • Repeat the bolus injection twice at 5 min intervals if an adequate circulation has not been restored
  • Give two further boluses of 100 ml at 5 min intervals
  • After another 5 min, increase the rate to 0.5 ml/kg/ min if an adequate circulation has not been restored

Give at a rate of 400 ml over 10 min

Continue infusion until stable

Follow-up action:

• Report cases from the United Kingdom to the National Patient Safety Agency (via

Whether or not lipid emulsion is administered, please also report cases to the LipidRescueTM site:

• If possible, take blood samples into a plain tube and a heparinised tube before and after lipid emulsion administration and at 1 h intervals afterwards. Ask your laboratory to measure LA and triglyceride levels (these have not yet been reported in a human case of LA intoxication treated with lipid).

Your nearest bag of Intralipid® is kept in the fridge in theatre 2

© The Association of Anaesthetists of Great Britain & Ireland 2007