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Background and Aims Local anesthetic systemic toxicity (LAST) is the most severe complication following local anesthetic (LA) administration. In orthopedic surgery, peripheral nerve blocks with LA have become increasingly popular due to its analgesic potential, thus making LAST more likely to occur in an orthopedic or trauma related clinical setting. Clinically, neurological presentation is the most common, but up to one-fifth of the reported cases present with isolated cardiovascular disturbance.

Results A 51-year-old woman, 60kg, with personal history of chronic hepatic disease and opioid dependency, underwent osteosynthesis of the fourth metacarpal. Ultrasound guided axillary approach to brachial plexus blockade was performed using 20ml of 0,5% ropivacaine (100mg). The LA was administrated fractionally and intravascular position was excluded by frequent aspiration. 5 minutes after LA administration, the patient related metallic taste, sialorrhea and an altered mental state – Glasgow Coma Scale 13. There was no cardiovascular alteration. LAST was rapidly assumed. General anesthesia was induced due to the altered mental status and LAST protocol was activated: administration of an 80ml bolus of lipidic emulsion 20%, 1000ml/h infusion during the first 10 minutes and 20 ml/h for 2hours. Anesthetic emergency was uneventful, with both motor and sensitive block of upper limb confirmed. The patient recovered previous mental status and remained 6 hours in Post Anaesthetic Care Unit continuously monitored without symptoms recurrence.

Conclusions LAST incidence has been decreasing mainly due to proper safety measures and advances in technique, thus making education and simulation crucial for speedy diagnosis and adequate treatment to assure a positive outcome.