Management and treatment of local anaesthetic toxicity

Local anaesthetics have been used within surgical practice since the late 1800s, when the ophthalmologist Carl Koller discovered the tissue numbing properties of cocaine (Odedra & Lyons 2010). Since that time, the ongoing development of anaesthetic drugs has provided many different local anaesthetics (LA) to clinical practice. The techniques for using these drugs in surgical practice have also developed, shaping the modern practices we know today. Increasing numbers of surgical procedures are now carried out under LA that once necessitated general anaesthetic, for example carotid endarterectomy as first described by Eastcott et al (1954). This type of procedure can now be safely carried out under LA but does require a large volume of the drug (up to 25 mls, see Table 1 for variations) to infiltrate a very vascular surgical field, and the LA may need supplementing during surgery (AIIman & Wilson 2006). The practice of routinely injecting large volumes of LA agents into surgical wounds to aid post-operative pain control also increases the risk of inadvertent intravascular injection that couldlead to LA toxicity (Parker et al 2009).