PedsCrit

Local Anesthetic Systemic Toxicity with Charles Berde

Jul 27, 2026
Guest
Charles Berde
Charles Berde, a Harvard pediatric anesthesiologist and pediatric pain specialist, explores local anesthetic systemic toxicity in children. He covers sodium-channel toxicity, warning signs, relative drug risks, pediatric vulnerabilities, and prevention of intravascular injection. The discussion also addresses lipid rescue, seizure management, resuscitation priorities, and when to activate ECMO for refractory cardiovascular collapse.
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ADVICE

Choose Safer Agents When The Situation Allows

  • Treat bupivacaine as the most cardiotoxic common agent; ropivacaine is only modestly safer after accounting for potency.
  • Consider chloroprocaine when appropriate because plasma esterases rapidly metabolize it, including in neonatal epidural practice.
ADVICE

Reduce Intravascular Injection Risk

  • Use ultrasound, moving-needle techniques, dilute concentrations, and aspiration to reduce intravascular injection risk; aspiration alone is imperfect.
  • Caudal and penile blocks appear frequently in pediatric LAST reports because blind techniques target vascular regions.
INSIGHT

Infants And Fragile Hearts Have Less Toxicity Reserve

  • Infants have more unbound drug, greater susceptibility of the myocardium, and immature hepatic metabolism, all increasing LAST risk.
  • Congenital heart disease, limited cardiac reserve, myopathies, and cardiodepressant medications require lower dosing and heightened vigilance.
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