Jornal de Toxicologia Clínica
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Local Anesthetic Systemic Toxicity Associated with Exparel Use

Samuel Hoffman, Stephen Petrou, Andrew Leubitz, Adam Schwartz

This case highlights a unique presentation of Local Anesthetic Systemic Toxicity (LAST) in a healthy young adult male following routine inguinal hernia repair surgery. Neurologic symptoms developed after the administration of both exparel and bupivacaine, albeit within their recommended safe concentrations. The symptoms occurred over an hour after administration and appeared to be more neurotoxic than cardiotoxic which is typically not what occurs with bupivacaine. Once the patient started to experience seizures after the operation was completed numerous doses of abortive IV benzodiazepines were given without successful termination of the seizures. Resolution only occurred after the patient received lipid emulsion therapy, a proposed therapy for LAST. Follow up labs and further investigation including CT and MRI of the brain did not reveal any other cause for the patient’s seizure. This case demonstrates a clear-cut occurrence of LAST with a rather unique presentation. This was a much delayed presentation with neurotoxic predominance associated with bupivacaine and exparel which is not routinely used in the Emergency Department (ED). This is a diagnosis that must be on the differential for all emergency medicine physicians regarding seizure of unknown origin.