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Local anesthetic systemic toxicity in children: a review of recent case reports and current literature
  1. Archana Singaravelu Ramesh1 and
  2. Karen Boretsky2
  1. 1Department of Anesthesiology, Yale New Haven Children's Hospital, New Haven, Connecticut, USA
  2. 2Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Archana Singaravelu Ramesh, Yale-New Haven Children's Hospital, New Haven, CT 06510-3202, USA; archanasramesh{at}gmail.com

Abstract

Background Local anesthetic systemic toxicity (LAST) in children occurs at an estimated rate of 8 per 100 000 blocks (95% CI 0.3 to 1.6). Due to the potential lethality of this iatrogenic complication, a better clarity of risk factors, clinical presentation, and prognosis may be clinically useful for contemporary treatment and prevention.

Methods An extensive literature search and detailed analysis of reported cases of LAST in patients less than 18 years of age published between April 2014 and August 2019 was performed. Clinical patterns were summarized.

Results Thirty-two cases of LAST were described in 17 published articles and 2 additional cases reported to lipidrescue.org, for a total of 34 cases. Three patients did not meet the inclusion criteria. Thirty-one cases were included in the analysis.

Discussion Infants represented a disproportionately large number of reports of LAST. The majority of local anesthetic doses were within currently published guidelines. Among the reported cases, penile and caudal blocks were the most commonly associated with LAST. Needle aspiration and test dosing with epinephrine failed to predict LAST with certainty. When LAST presented with severe cardiac compromise, intravenous lipid emulsion was given within 10 min in 43% of cases (13 of 30 reported cases). The vast majority of children were under general anesthesia when local anesthetic medications were administered. In children under general anesthesia, LAST presented with cardiac manifestations in 90% of cases (19 of 21 cases). There were no deaths or long-term morbidity reported.

  • local
  • anesthesia
  • conduction
  • treatment outcome

Data availability statement

Data are available in a public, open access repository. This submission is a review of case reports and case series on pediatric local anesthetic systemic toxicity published in the literature between 2014 and 2019.

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Data availability statement

Data are available in a public, open access repository. This submission is a review of case reports and case series on pediatric local anesthetic systemic toxicity published in the literature between 2014 and 2019.

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Footnotes

  • Contributors Both authors contributed to planning, designing, and writing of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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