Local Anesthetic Systemic Toxicity (LAST)

Ivo Křikava, MD, PhD, Andrej Jaroš, MD, Tetiana Kozachenko, Katarína Bernáthová
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Local Anesthetic Systemic Toxicity (LAST)

Local anesthetics are an essential part of modern anesthesia and regional analgesia, but improper administration can lead to serious, potentially life-threatening complications—known as local anesthetic systemic toxicity (LAST). The clinical manifestations of LAST can be diverse and often subtle, ranging from neurological symptoms to cardiovascular disturbances, which makes timely recognition challenging. Proper dosing, injection technique, and monitoring are key to preventing these complications. In this interactive algorithm, you will learn which factors increase the risk of LAST, how to recognize it early, and how to respond effectively if it occurs.

2026
Systemic toxicity of local anesthetics
LAST
intralipid
lipid rescue
cardiotoxicity
neurotoxicity
Published at: 1.6.2026

Review

Denis Buršík, MD
Denis Buršík, MD

Educational materials focused on the prevention and treatment of Local Anesthetic Systemic Toxicity (LAST) are extremely valuable not only for anesthesiologists, but for all healthcare professionals who encounter regional anesthesia techniques in their practice. Although the incidence of LAST is relatively low according to available data (1–2 cases per 1,000 nerve blocks), it remains a potentially life-threatening complication in which the ability to recognize symptoms early and initiate appropriate treatment plays a crucial role.

The presented algorithm clearly describes the two main clinical scenarios that may be encountered in practice. The individual steps are well structured, and their significance is explained in an understandable manner. I consider the distinction between a conscious patient and a patient under general anesthesia particularly beneficial, as the initial manifestations of toxicity may differ between these groups. I also appreciate the inclusion of good practice principles, which play a key role in the prevention of LAST.

Sources

LOTT, Carsten et al. European Resuscitation Council Guidelines 2025: Special circumstances in resuscitation. Resuscitation [online]. 2025, vol. 215, Supplement 1, article 110753 [cited 2026-03-29]. DOI: 10.1016/j.resuscitation.2025.110753. Available from: https://www.resuscitationjournal.com/action/showPdf?pii=S0300-9572%2825%2900265-5 

KLUČKA, Jozef. Lipid rescue [online]. Akutně.cz, [year not specified] [cited 2026-03-29]. Available from: https://www.akutne.cz/res/publication/000159/lipid-rescue-klu-ka-j.pdf 

CVACHOVEC, Karel et al. Recommendations for the treatment of toxic reactions after administration of local anesthetics [online]. Czech Society of Anaesthesiology, Resuscitation and Intensive Care Medicine (ČSARIM), 2012 [cited 2026-03-29]. Available from: https://www.csarim.cz/getmedia/fab99007-ab30-4d0e-bb2a-9b425135b9a6/doporuceni-pro-lecbu-toxicke-reakce-po-podani-lokalnich-anestetik-2012.pdf.aspx 

Learning targets

1. The student understands the principles of safe local anesthetic (LA) administration.
2. The student can identify systemic toxic reactions to LAs.
3. The student knows the treatment protocol for LA systemic toxicity (LAST).

Key points

Safe administration of LA – calculation of the maximum dose according to patient weight and the anesthetic used, aspiration before injection, use of the lowest effective dose, and patient monitoring. Recognition of LA toxicity – neurological symptoms (perioral paresthesia, tinnitus, metallic taste, seizures) and cardiovascular manifestations (hypotension, arrhythmias, cardiac arrest). Management of LA toxicity – discontinuation of LA administration, stabilization of vital functions, seizure treatment, and administration of Intralipid 20% (1.5 mL/kg IV bolus, then 0.25 mL/kg/min).

Other versions of the algorithm

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External links

LipidRescue™. Treatment regimens. Online. Available at: http://lipidrescue.squarespace.com/treatment-regimens/

Algorithms