Did Preoperative Fixation on Choice of Anesthetic Confound Assessment of Alternative Techniques?

We commend Vadi et al.¹  for their valuable case report of local anesthetic systemic toxicity (LAST) and for highlighting human factors that likely contributed to the poor outcome. At the risk of displaying outcome or hindsight bias, we would like to highlight two further educational aspects of the case. One possible scenario is that in deciding on technique the anesthesiologist was fixated on using a peripheral nerve block and discounted the relative merits of alternative techniques. It should be emphasized that for this patient, there were no contraindications to general or neuraxial anesthesia. The blocks necessitated a relatively large total dose of local anesthetic. Moreover, low body weight and site of injection are recognized, independent risk factors for LAST² ; notably, that site of injection is associated with high serum levels³  of local anesthetic and increased risk of LAST.⁴ 

The authors’ indicated that they thought the presentation of LAST was atypical. However, the presentation and onset of LAST are extremely variable. Loss of consciousness is a known symptom of LAST and may or may not be preceded by prodromal features.⁵  Recognizing such clinical variability can aid in the prompt diagnosis and management of LAST.

The incorporation and discussion of human factors in the case scenario is particularly welcome. The value of such nontechnical skills are important components of anesthesiology practice and particularly pivotal in crisis resource management (CRM).⁶  Lack of implementation of CRM might have contributed to the delay in calling for help and secondarily to the poor outcome. For instance, as a first step in CRM, calling for aid and engaging helpers in a dialogue assists in critical decision making and might have included saying something like: “I think this patient may have local anesthetic toxicity, but I am unsure; it is unusual, she has many medical problems, what do you think?” This would encourage a structured discussion of the differential diagnosis and treatment priorities. One important by-product of CRM is that all clinicians should feel empowered to make critical treatment decisions. CRM applies to many scenarios in anesthesiology and should be considered important universally, especially in crisis management scenarios like LAST.

In sum, we believe attention to systems issues including consideration of all management options and timely use of CRM can reduce the risk of LAST specifically and regional anesthesia in general.

The authors declare no competing interests.