Local anesthetic systemic toxicity with liposomal bupivacaine: a case series and literature review

BACKGROUND: Local Anesthetic Systemic Toxicity (LAST) is an uncommon complication, with manifestations ranging from mild, non-specific neurological symptoms to severe cardiac arrest. Toxicity specifically associated with liposomal bupivacaine is even more rarely documented in the literature. We report two cases of LAST following the administration of liposomal bupivacaine and provide a review of previously reported cases. CASE PRESENTATION: Case 1: A 55-year-old male received 266 mg of liposomal bupivacaine via intercostal nerve block during thoracoscopic lobectomy. During skin closure, he developed cardiac arrest and recurrent ventricular fibrillation. He was successfully extubated and weaned off all vasopressors two hours after lipid emulsion administration and subsequently recovered. Case 2: A 67-year-old male received 266 mg of liposomal bupivacaine via incision infiltration after lobectomy. Shortly after PACU arrival, he developed agitation, fixed gaze, and increased muscle tone. Lipid emulsion infusion led to neurological improvement within five minutes, and he was subsequently discharged successfully. CONCLUSIONS: These two cases highlight the potential for catastrophic LAST associated with liposomal bupivacaine. To mitigate this risk, we recommend reducing the dose of local anesthetics when injecting into highly vascular areas and performing careful aspiration during injection to prevent intravascular injection. Furthermore, the early administration of intravenous lipid emulsion should be strongly considered upon any suspicion of LAST.