2025 FSA Podium and Poster Abstracts

Introduction: Local anesthetic systemic toxicity (LAST) is a serious and potentially fatal complication resulting from the systemic absorption of local anesthetics. It can occur after any route of administration of local anesthetic and typically presents with both central nervous system and cardiovascular symptoms. CNS manifestations may include seizures, agitation, syncope, dysarthria, perioral numbness, confusion, obtundation, and dizziness. Cardiovascular toxicity may present with asystole, ventricular fibrillation, or ventricular tachycardia. Early recognition and prompt intervention are vital for effective management of LAST. Treatment often involves advanced cardiac life support measures in addition to intravenous lipid emulsion administration in life-threatening cases, particularly following exposure to bupivacaine. This case highlights a rare instance of LAST in a patient undergoing AV fistula ligation for an infected AV fistula.

Case Report/Methods: Patient is a 53-year-old male with past medical history significant for end stage renal disease on dialysis, hypertension, diabetes mellitus, atrial fibrillation, peripheral artery disease and coronary artery disease status post coronary artery bypass graft. He presented to the emergency department with increased left upper extremity fistula size and suspicion for possible infection of fistula site. Patient was scheduled for left artery/vein (AV) fistula revision and was taken to the operating room. He was placed in the supine position under Monitored Anesthesia Care and the surgeons injected 15ml of 1% lidocaine and Marcaine mixture under the skin circumferentially around the AV site. A 5 cm incision was made along the fistula, and within minutes the patient became hypotensive (blood pressure 54/31) and bradycardic (heart rate 50). The patient entered cardiac arrest, ACLS protocol was begun, and the surgery was aborted. The patient was intubated by the anesthesia team and multiple rounds of cardiopulmonary resuscitation (CPR) were initiated. 34g of 20% lipid emulsion was administered given the high suspicion for LAST, with a second 34g bolus administered 15 minutes later. A right femoral arterial line and right femoral vein central line were placed, and the patient regained spontaneous circulation. At this time, a temporary tunneled dialysis catheter was placed in the right femoral vein and the patient was taken to the intensive care unit (ICU) for recovery. After two weeks in the ICU an MRI showed anoxic brain injury and a tracheostomy tube was placed. One week later, he entered cardiac arrest for a second time and was successfully resuscitated after 9 minutes. He remains in the ICU as a functional quadraplegic on a ventilator 1.5 months after his initial arrest, with terminal condition prognosis.

Conclusion: LAST results from the systemic absorption of local anesthetics, with the most common cause being accidental intravascular injection during local anesthetic administration. This case illustrates the potential for LAST to occur even during routine procedures such as AV fistula ligation. Clinicians must remain vigilant for signs and symptoms of LAST, even in patients undergoing procedures that are considered low-risk. Prompt identification and appropriate management are critical in preventing fatal outcomes.