Cases of toxic blood levels* without symptoms
| Publication | Number of pts | Hourly infusion (mg/kg/hour) | 24-hour dose (mg/kg) | Max 24-hour dose adjusted for 70 kg patient (mg) | Space | Surgery | Peak conc. (peak unbound) (mg/L)—[site of blood draw] | Peak time (hours) | Symptoms |
| Bupivacaine | |||||||||
| Berrisford et al, 199319 | 11 | 0.45 | 11.7 (11–12.9) | 903 | PVB | Thoracotomy | 9.27 [central venous] | 48 | NR |
| Dauphin et al, 199727 | 9 | 0.5 | 13.5 | 945 | PVB | Thoracotomy | 6† | 72 | NR |
| Perttunen et al, 199523 | 1+ | 0.2 | 5.2 (2.5–9.8) | 686 | PVB | Thoracotomy | 5.1 [arterial] | 48 | NR |
| Theissen et al, 199321 | 4 | 0.39 | 10.2 (10–10.4) | 728 | PVB | Thoracotomy | >2.6† | 36 | NR |
| Català et al, 199626 | 1 | 0.18 | 5.4 (5.–6.0) | 420 | PVB | Thoracotomy | 2.4† | 15 | NR |
| Bimston et al, 199929 | 1 | 0.14 | 4.7 (2.4–6.4) | 357 | PVB | Thoracotomy | 2.1† | 48 | NR |
| D’Souza et al, 201055 | 1 | 0.21 | 5.1 (3.4–6.9) | 476 | PVB | Lobectomy | 2.2† | 24 | NR |
| Total: | 28 | 0.42±0.11 | 11±2.7 | 832±167 | 37±14 | NR | |||
| Ropivacaine | |||||||||
| Kumar et al, 2014161 | 8 | 0.5 (0.33–0.6) | 14.1 (9.5–17.0) | 1190 | TAP | Abdominal | 5.7(0.12)† | 48 | Qt prolonged to 457 |
| Hessian et al, 2013150 | 4 | 0.41 (0.29–0.62) | 12.7 (9.1–19.2) | 1344 | TAP | Laparotomy | 4 patients >3.4(0.135) [venous] | 24 | NR |
| Marret et al, 2005123 | 20 | 0.5 | 12.0 | 840 | PVB | Thoracotomy | 2.83±1.31 [venous] | 24–48 | NR |
| Ollier et al, 2015162 | 16 (19 total) | 0.25 | 9.0 | 630 | TAP | Liver resection | 4.3(0.09) [venous] | 12 | NR |
| Sondekoppam et al, 2019219 | 9 | 0.4 | 12.5 | 875 | PVB | Laparotomy | >4 [venous] | 24 | NR |
| Total | 57 | 0.41±0.11 | 11.6±1.8 | 871±217 | 30±11 | ||||
*Toxic blood level defined based on median total plasma concentration (given inconsistency of reporting of unbound levels) from Knudsen et al (eg, venous ropivacaine=2.2 mg/L, venous bupivacaine=2.1 mg/L, arterial ropivacaine=4.3 mg/L, arterial bupivacaine=4.0 mg/L). If sample source was unreported, we assumed peripheral venous draw.
†Site not reported.
NR, not reported; pts, patients; PVB, paravertebral.