Local anesthetic systemic toxicity (LAST) can occur with liposomal bupivacaine, presenting as severe cardiac or neurological events, and early intravenous lipid emulsion administration leads to successful recovery.
Key Findings
Results
A 55-year-old male developed cardiac arrest and recurrent ventricular fibrillation following 266 mg of liposomal bupivacaine administered via intercostal nerve block during thoracoscopic lobectomy.
Cardiac arrest occurred during skin closure phase of the procedure.
The patient received lipid emulsion administration as treatment.
The patient was successfully extubated and weaned off all vasopressors within two hours after lipid emulsion administration.
The patient subsequently recovered fully.
The intercostal space is a highly vascular area, which may have contributed to systemic absorption.
Results
A 67-year-old male developed neurological symptoms of LAST shortly after PACU arrival following 266 mg of liposomal bupivacaine administered via incision infiltration after lobectomy.
Neurological symptoms included agitation, fixed gaze, and increased muscle tone.
Symptoms developed shortly after arrival in the post-anesthesia care unit (PACU).
Lipid emulsion infusion led to neurological improvement within five minutes.
The patient was subsequently discharged successfully.
The same dose (266 mg) was used as in Case 1 but via a different administration route (incision infiltration).
Results
LAST associated with liposomal bupivacaine can present across a wide clinical spectrum, ranging from mild neurological symptoms to severe cardiac arrest.
Manifestations of LAST range from 'mild, non-specific neurological symptoms to severe cardiac arrest' according to the authors.
Case 1 represented the severe end of the spectrum with ventricular fibrillation and cardiac arrest.
Case 2 represented a primarily neurological presentation without cardiac involvement.
Toxicity specifically associated with liposomal bupivacaine is described as 'even more rarely documented in the literature.'
Both cases used the same dose of 266 mg liposomal bupivacaine.
Results
Early intravenous lipid emulsion administration was effective in treating LAST from liposomal bupivacaine in both reported cases.
In Case 1, the patient was weaned off vasopressors within two hours of lipid emulsion administration following cardiac arrest.
In Case 2, neurological improvement occurred within five minutes of lipid emulsion infusion.
The authors state that 'early administration of intravenous lipid emulsion should be strongly considered upon any suspicion of LAST.'
Both patients were ultimately discharged successfully after lipid emulsion treatment.
Discussion
The authors recommend dose reduction of local anesthetics in highly vascular areas and careful aspiration during injection to prevent intravascular injection of liposomal bupivacaine.
Intercostal nerve block, used in Case 1, is identified as a highly vascular administration site.
Careful aspiration before injection is recommended to detect inadvertent intravascular placement.
These recommendations are framed as risk mitigation strategies for LAST associated with liposomal bupivacaine.
The paper provides a literature review of previously reported cases in addition to the two new cases.
What This Means
This research describes two patients who experienced a rare but potentially life-threatening complication called Local Anesthetic Systemic Toxicity (LAST) after receiving liposomal bupivacaine, a long-acting numbing medication commonly used for post-surgical pain control. In the first case, a 55-year-old man went into cardiac arrest with a dangerous heart rhythm (ventricular fibrillation) during surgery. In the second case, a 67-year-old man developed neurological symptoms including agitation, a fixed stare, and increased muscle stiffness after surgery. Both patients received the same dose of the drug (266 mg) but through different methods — one via nerve block between the ribs and one directly into the surgical incision site.
Both patients recovered after being treated with intravenous lipid emulsion (a fat-based IV solution), which works by binding to the local anesthetic and reducing its toxic effects in the bloodstream. The first patient stabilized within two hours, and the second showed neurological improvement within just five minutes of treatment. The authors also reviewed other previously published cases of this complication to provide a broader picture of how LAST from liposomal bupivacaine can present.
This research suggests that even liposomal bupivacaine — which is often considered safer because it releases the drug slowly — can cause serious systemic toxicity in rare cases. The findings highlight the importance of being cautious when injecting local anesthetics near highly vascular (blood-rich) areas, checking carefully before injecting to avoid accidentally delivering the drug into a blood vessel, and acting quickly with lipid emulsion treatment at the first sign of LAST. Clinicians and patients should be aware that this complication, while rare, can occur even with newer formulations of local anesthetics.
Zhang L, Lin Y, Qiu Y. (2026). Local anesthetic systemic toxicity with liposomal bupivacaine: a case series and literature review.. BMC anesthesiology. https://doi.org/10.1186/s12871-026-03922-9