Thi Anh Tuyet Cao, Thang Toan Nguyen
Epidural analgesia is an effective method of pain relief, providing prolonged and continuous analgesia with a relatively low risk of systemic toxicity. Nevertheless, LAST may still occur, particularly during prolonged administration or in vulnerable populations, such as elderly patients and those with hepatic, renal, or cardiovascular dysfunction. In the critical care setting, clinicians should maintain a high index of suspicion for LAST while excluding other differential diagnoses, including shock, stroke, or pulmonary embolism. Importantly, the potential accumulation of local anesthetics during epidural analgesia should be considered even when dosing adheres to current recommendations, as age-related physiological and pharmacokinetic changes may increase susceptibility to toxicity. This case also highlights the important role of intravenous lipid emulsion (ILE) as an effective rescue therapy in the management of LAST, with rapid improvement in neurological manifestations following treatment.
BACKGROUND: Elderly patients have a higher likelihood of undergoing surgical procedures compared to younger populations, a factor associated with increased perioperative mortality and anesthesia-related morbidity. Regional anesthesia in geriatric patients offers a favorable safety profile, optimizes analgesia, and contributes to reducing postoperative complications, particularly within the framework of enhanced recovery after surgery (ERAS) protocols. Nevertheless, local anesthetic systemic toxicity (LAST) remains a rare yet potentially life-threatening complication in the context of epidural analgesia. Its severity is amplified in scenarios involving prolonged local anesthetic infusion or in patients with elevated susceptibility due to age-related physiological changes or comorbidities.
CASE PRESENTATION: A case report details an instance of LAST induced by continuous epidural administration of bupivacaine 0.1% in a 95-year-old female patient following surgery for bowel obstruction. We describe the clinical presentation, diagnostic considerations, therapeutic interventions, and subsequent recovery.
CONCLUSION: Epidural analgesia is an effective method of pain relief, providing prolonged and continuous analgesia with a relatively low risk of systemic toxicity. Nevertheless, LAST may still occur, particularly during prolonged administration or in vulnerable populations, such as elderly patients and those with hepatic, renal, or cardiovascular dysfunction. In the critical care setting, clinicians should maintain a high index of suspicion for LAST while excluding other differential diagnoses, including shock, stroke, or pulmonary embolism. Importantly, the potential accumulation of local anesthetics during epidural analgesia should be considered even when dosing adheres to current recommendations, as age-related physiological and pharmacokinetic changes may increase susceptibility to toxicity. This case also highlights the important role of intravenous lipid emulsion (ILE) as an effective rescue therapy in the management of LAST, with rapid improvement in neurological manifestations following treatment.