EM Vivas · Local anaesthesia & topical agents
LAST recognition and lipid emulsion
Clinical viva on LAST and lipid rescue.
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Target exams
ACEMFRCEMABEM
Prompt
After a bupivacaine block the patient has tinnitus then a seizure and wide-complex bradycardia. Discuss recognition, differential, and lipid rescue using fetched ASRA/Karaoglu/Fettiplace facts.
Interpretation
Reveal interpretationShowHide
This is LAST until proven otherwise. Neal 2018: delayed presentations now more common with ultrasound (fewer intravascular injections), infiltration and continuous infusions; small size and sarcopenia increase risk. Management: stop injection, oxygen/airway, benzodiazepine, lipid bolus 1.5 mL/kg (Karaoglu recommended bolus). Infusion rates are not in the fetched ASRA abstracts. Fettiplace: lipid shuttle plus cardiotonic/postconditioning; calcium-channel and mitochondrial-mass-effect hypotheses retired.[1][2][3][4]
References4ShowHide
- [1]Neal JM, Neal EJ, Weinberg GL. American Society of Regional Anesthesia and Pain Medicine Local Anesthetic Systemic Toxicity checklist: 2020 version Reg Anesth Pain Med, 2021.PMID 33148630
- [2]Neal JM, Barrington MJ, Fettiplace MR, Gitman M, Memtsoudis SG, Mörwald EE, Rubin DS, Weinberg G. The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017 Reg Anesth Pain Med, 2018.PMID 29356773
- [3]Karaoglu RO, Toprak Karaoglu A, Kumas Solak S, Sevdi MS, Demirgan S. Awareness and preparedness for local anesthetic systemic toxicity among surgical clinicians: a multi-center cross-sectional survey study BMC Anesthesiol, 2026.PMID 42399827
- [4]Fettiplace MR, Weinberg G. The Mechanisms Underlying Lipid Resuscitation Therapy Reg Anesth Pain Med, 2018.PMID 29356774