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One Hundred Years Later, I Can Still Make Your Heart Stop and Your Legs Weak: The Relationship Between Regional Anesthesia and Local Anesthetic Toxicity

The association between regional anesthesia and local anesthetic systemic toxicity and neurotoxicity is well established. However, as with all relationships, the roles and concerns have evolved over time. Initial descriptions focused on systemic toxicity, most likely because of the popularity of infiltrative and peripheral techniques which required large doses and/or concentrations of local anesthetics.1 Advances in local anesthetic synthesis, neural blockade techniques, and regional anesthesia equipment technology have often been linked to reports of serious complications. For example, the long-acting amides allowed prolonged anesthesia and analgesia but were associated with cardiac arrest after intravascular injection.2 Likewise, cases of cauda equina syndrome followed the introduction of spinal microcatheters.3 The ensuing laboratory studies, clinical investigations, and postmarketing surveillance that were performed to evaluate the increased frequency of a previously rare event often yielded conflicting conclusions and recommendations. As a result, it is difficult to determine if the subsequent decrease in the complication was a result of altered clinical practice or avoidance of the associated technique. Recognizing the need to summarize and update this often controversial area of regional anesthetic practice, the American Society of Regional Anesthesia and Pain Medicine convened a “Conference on Local Anesthetic Toxicity,” which was held November 17-18, 2001, in Miami. This symposium was an invited colloquium of acknowledged international researchers who were brought together to share ideas and advances in their area of expertise with other conferees, who by definition had more than a passing interest in local anesthetic toxicity. After this one and a half day conference, then Editor-in-Chief David L. Brown, MD, invited several presenters to submit manuscripts to be considered for publication in Regional Anesthesia and Pain Medicine. Each article underwent peer review, in addition to editorial oversight from Drs. Brown and Neal. The first 6 articles of the current issue of Regional Anesthesia and Pain Medicine are representative topics from the conference, and essentially represent a special supplement within this issue.4-9 Future issues of the journal will include more work from Local Anesthetic Toxicity Conference presenters. Readers of Regional Anesthesia and Pain Medicine should be aware of the process by which special articles such as these are selected and reviewed because there are subtle differences as compared with standard original or review articles. It is important to realize that some articles contain more opinion than would be accepted in the normal peer-review process. This is both necessary and as it should be. As recognized experts, many of the authors are offering their learned