Neal JM et al: ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med 2010;35:152.
Pollock JE: Transient neurologic symptoms: Etiology, risk factors, and management. Reg Anesth Pain Med 2002;27:581.
Priest BT: Future potential and status of selective sodium channel blockers for the treatment of pain. Curr Opin Drug Discov Dev 2009;12:682.
Rigler ML et al: Cauda equina syndrome after continuous spinal anesthesia. Anesth Analg 1991;72:275.
Rose JS, Neal JM, Kopacz DJ: Extended-duration analgesia: Update on micro-spheres and liposomes. Reg Anesth Pain Med 2005;30:275.
Ruetsch YA, Boni T, Borgeat A: From cocaine to ropivacaine: The history of local anesthetic drugs. Curr Top Med Chem 2001;1:175.
Sakura S et al: Local anesthetic neurotoxicity does not result from blockade of voltage-gated sodium channels. Anesth Analg 1995;81:338.
Schneider M et al: Transient neurologic toxicity after hyperbaric subarachnoid anesthesia with 5% lidocaine. Anesth Analg 1993;76:1154.
Sirianni AJ et al: Use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Ann Emerg Med 2008;51:412.
Taniguchi M, Bollen AW, Drasner K: Sodium bisulfite: Scapegoat for chloroprocaine neurotoxicity? Anesthesiology 2004;100:85.
Tremont-Lukats IW et al: Systemic administration of local anesthetics to relieve neuropathic pain: A systematic review and meta-analysis. Anesth Analg 2005;101:1738.
Weinberg GL: Lipid Emulsion Infusion: Resuscitation for local anesthetic and other drug overdose. Anesthesiology 2012;117:180.
Weinberg GL et al: Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats. Anesthesiology 1998;88:1071.
If a spinal anesthetic technique were selected, bupivacaine would be an excellent choice. It has an adequately long duration of action and a relatively unblemished record with respect to neurotoxic injury and transient neurologic symptoms, which are the complications of most concern with spinal anesthetic technique. Although bupivacaine has greater potential for cardiotoxicity, this is not a concern when the drug is used for spinal anesthesia because of the extremely low doses required for intrathecal administra-tion. If an epidural technique were chosen for the surgical procedure, the potential for systemic toxicity would need to be considered, making lidocaine or mepivacaine (generally with epinephrine) preferable to bupivacaine (or even ropi-vacaine or levobupivacaine) because of their better thera-peutic indexes with respect to cardiotoxicity. However, this does not apply to epidural administration for postopera-tive pain control, which involves administration of more dilute anesthetic at a slower rate. The most common agents used for this indication are bupivacaine, ropivacaine, and levobupivacaine.
Marieke Kruidering-Hall, PhD, & Lundy Campbell, MD