Cases of local anesthetic systemic toxicity
| Publication | No. of pts | Hourly infusion (mg/kg/hour) | 24-hour dose (mg/kg) | Max 24-hour adjusted for 70 kg patient (mg) | Space | Surgery | Peak conc. (peak unbound) (mg/L)—[site of blood draw] | Peak time (hrs) | Symptoms |
| Bupivacaine | |||||||||
| Womack et al, 2019109 | 2 | 0.36 (0.29–0.42) | 10.7 (8.3–13.1) | 917 | PVB | Rib fractures | NR | N/R | Agitation, metallic taste |
| Fagenholz et al, 201265 | 1 | 0.38 | 10.8 (10.3–12.1) | 847 | PVB | Lobectomy | 8* | 58.5 | Seizure following bolus |
| Mohta et al, 200952 | 1 | 0.375 | 10.5 (7.5–13.5) | 945 | PVB | Rib fractures | NR | 68 | Convulsions, hypotension |
| Richardson et al, 199525 | 5 | 0.5 | 13.6 (12.9–13.6) | 952 | PVB (Interpleural group) | Thoracotomy | NR | NR | Confusion, heart failure, death |
| Richardson et al, 199930 | 3 | 0.5 | 13.0 (12.1–13.1) | 847 | PVB | Thoracotomy | NR | NR | Confusion, somnolence, arrhythmia, death |
| Total: | 12 | 0.46±0.06 | 12.48±1.4 | 901±52 | 63±7 | ||||
| Ropivacaine | |||||||||
| Bishop et al, 2019213 | 1 | 0.29 (0–0.4) | 9.0 (2.1–11.7) | 819 | PVB | Thoracic surgery | NR | NR | Perioral numbness |
| Calenda et al, 2014157 | 1 | 0.29 | 7.7 | 539 | PVB | Thoracotomy | 3.21 [venous] | 11 | LOC, hypotension, Vfib, VTach, death |
| Cantó et al, 2003122 | 3 | 0.225 | 6.2 (6.2–6.4) | 448 | PVB | CABG/Valve repair | NR | NR | PVC, Persistent somnolence |
| Ghisi et al, 2015167 | 1 | 0.38 (0.15–0.65) | 10.3 (4.0–17.1) | 1197 | PVB | Laparoscopic bowel surgery | NR | 48 | Tremors following bolus |
| Hessian et al, 2013150 | 1 | 0.62 | 12.7 (9.1–19.2) | 1344 | TAP | Laparotomy | 3.48(0.135) [venous] | 6 | Facial and arm numbness/tingling |
| Ho et al, 2016173 | 7 | 0.5 | 13.8 | 966 | PVB | CABG | 9 [arterial] | 48 | Confusion, combativeness, somnolence, |
| 1 | 0.5 | 13.8 | 966 | PVB | CABG | >3 [arterial] | 5–15 min | Involuntary screaming, tonic-clonic muscle contractions | |
| Petersen et al, 2013154 | 1 | 0.125 (0.1–0.14) | 4.3 (3.7–4.8) | 336 | TAP | None | NR | 1 | NR |
| Tsang et al, 2016177 | 1 | 0.2 | 4.9 | 343 | PVB | Thoracotomy | 2.1 [venous] | 37 | Agitation, burning sensation of penis and legs |
| Yamauchi et al, 2017199 | 1 | 0.5 (0.43–0.56) | 11.9 (10.3–13.4) | 938 | PVB | Thoracotomy | NR | 3.5 | Respiratory depression resolved by stopping infusion |
| Total | 18 | 0.39±0.14 | 10.5±3.7 | 810±71 | 33±5 | ||||
*Site not reported.
CABG, coronary artery bypass graft; LOC, loss of consciousness; No, number; NR, not reported; pts, patients; PVB, paravertebral; PVC, premature ventricular contraction; Vfib, ventricular fibrillation; VTach, ventricular tachycardiac.