Article Text

Multidisciplinary simulation of local anaesthetic systemic toxicity improves diagnostic and treatment skills and self-confidence for pain clinic procedural staff
  1. Robert Ackerman1,
  2. Matthew Riley2,
  3. Muhammad A Farooq Anwar2,
  4. Duran Mitchell2,
  5. Kevin Vorenkamp2,
  6. Ankeet Udani2,
  7. Peter Yi2
  1. 1Moffitt Cancer Center, Tampa, Florida, USA
  2. 2Duke University, Durham, North Carolina, USA
  1. Correspondence to Dr Peter Yi; peter.yi{at}


Local anaesthetic systemic toxicity (LAST) is a rare complication after outpatient interventional pain procedures, which can present as an emergent and life-threatening condition. Proficiency and confidence in managing this rare situation necessitates strategies to ensure team members can perform necessary tasks. The primary objective was to familiarse the pain clinic procedural staff—physicians, nurses, medical assistants, and radiation technologists—with concise and current instruction and an opportunity to practice in a controlled environment. A two-part series was designed and led by the pain physicians, with the assistance of the simulation centre and clinic staff. A 20 min didactic session was held to familiarise the providers with relevant details and information regarding LAST. Then, 2 weeks later, all team members participated in a simulation exercise intended to portray a LAST encounter, tasking participants to recognise and manage the condition in a team-based model. Before and after the didactic and simulation sessions, the staff was administered a questionnaire to assess knowledge of LAST signs, symptoms, management strategies, and priorities. Respondents were better able to identify signs and symptoms of toxicity and prioritise management steps, and felt more confident in recognising symptoms, starting treatment and coordinating care. Furthermore, participants emphasised the positive of debriefing, practicing a rare situation and learning strategies for effective communication, team dynamics and role clarity.

Format Small group didactic session, simulation exercise in a clinical simulation lab.

Target audience Attending, fellow, and resident physicians, medical students, registered nurses, certified medical assistants, and radiation technologists working in a pain clinic procedure suite.

Objectives To acquaint the pain clinic procedural staff with current training related to LAST and an opportunity to practice in a controlled environment.

  • Simulation
  • Team training
  • Patient safety

Data availability statement

Data are available on reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • LAST is a rare but feared complication in the outpatient clinical setting. The traditional ways of educating staff about identifying and managing this life-threatening condition may not lead to effective team collaboration in an acute setting. Simulation-based teaching has become part and parcel of medical student and resident education and could be used as a practical learning tool by clinical staff.


  • This study successfully demonstrates how simulating a rare but emergent scenario in a controlled non-clinical setting can increase the confidence of the clinical staff to deal with a potential real-life situation.


  • Interactive lectures and simulated clinical environments can help close the medical knowledge gap and increase collaboration between physicians and other clinical staff. Widespread adoption of these practices by various healthcare systems for mandatory training of healthcare providers will help build trust and improve team dynamics.


Outpatient interventional pain procedures have become widely accessible due to ongoing technological advancements. Although a much-needed alternative to chronic opioid management, invasive procedures have potential complications and should be performed in the safest way possible. An analysis of the American Society of Anesthesiologists Closed Claims Project showed a significant increase in claims related to chronic pain management over the last two decades.1 Although uncommon compared with the perioperative setting, periprocedural complications such as medication-related errors, vasovagal reactions, haemodynamic changes, nerve injuries, pneumothorax, allergic reactions and local anaesthetic systemic toxicity (LAST) may be encountered in a chronic pain clinic.2 LAST is the most serious complication and may lead to life-threatening cardiovascular and neurological outcomes. Neurological manifestations are recognisable and more prevalent in an outpatient setting without patients undergoing general anaesthesia.3 Several factors, such as the type of local anaesthetic, medication dosage, patient demographics, procedural technique and practice setting, influence LAST incidence.4 Some of the initial signs and symptoms include lightheadedness, perioral numbness, tinnitus, cardiac rhythm changes and muscle twitching. If untreated, it can result in seizures, ventricular fibrillation, cardiac arrest, and death.3 Most strategies used by providers to combat LAST focus on prevention, but early diagnosis and treatment could prevent lethal consequences.

While the details of LAST management are beyond the scope of this manuscript, lipid emulsion, in addition to cardiopulmonary resuscitation, has been used as the first-line therapy for over a decade. It is a vital component of the LAST rescue kit. The American Society of Regional Anesthesia and Pain Medicine (ASRA) recommends early administration of lipid emulsion while treating LAST, which requires familiarisation by the clinical staff.5 6 Comprehensive understanding of LAST pathology, adequate preparation and sufficient training of the clinical staff can help with prevention, prompt recognition and appropriate patient resuscitation in an outpatient chronic pain clinic. Standardised operations and team collaboration in a chronic pain clinic can ensure a safe clinical environment and optimal patient outcomes. Routine training and refresher programmes for clinical staff help with risk reduction and promote a culture of patient safety. Team-based learning models using a simulated clinical environment have become part of the training of physicians and clinical staff.7 8 Simulation provides a protected space for providers to test their individual knowledge and assess how well the team works in a replicated clinical scenario. It can help with the development and implementation of a crisis management plan where all team members effectively recognise their roles while managing rare clinical complications.9 As we demonstrate here, an initial didactic session followed by a simulated clinical scenario and postsession debriefing are integral components of a successful team-based learning experience.

Activity description

The educational activities within this design consisted of an interactive lecture and an immersive, interprofessional simulation. The educational activities were targeted at the registered nurses, certified medical assistants and radiation technologists of our pain medicine clinic. An initial survey was used to measure the effect of educational activities on the staff’s ability to recognise symptoms and implement treatment of local anaesthetic toxicity. The survey consisted of questions focused on the symptoms and treatment of LAST as well as the individual’s comfort with these topics (online supplemental survey 1).

Supplemental material

The interactive lecture was developed using the most recent evidence and clinical guidelines from the New York School of Regional Anesthesia,10 ASRA6 and The information outlined within the lecture focused on the following: pharmacological mechanism for local anaesthetic toxicity, the neurological symptoms of toxicity, cardiovascular symptoms of toxicity and treatment. The outline of treatment followed the most recent guidelines published by ASRA focusing on early call for help, using a LAST rescue kit, early administration of lipid emulsion and modified advanced cardiac life support. At the end of the lecture, the attendees were sent a full copy of the slides for continued self-study.

Approximately 2 weeks after the interactive lecture, the office staff participated in an interprofessional simulation taking place in our simulation centre. The simulation consisted of a LAST event occurring immediately after an intercostal nerve block. The interprofessional team was then required to reach the correct diagnosis and treat the patient according to up-to-date guidelines. After the simulation, the staff was administered the same LAST diagnosis and management knowledge survey as well as extra questions directly related to the simulation exercise (online supplemental survey 2).


As described above, the initial baseline knowledge of symptoms and treatment for LAST as well as the personal comfort in applying this knowledge was measured through a pre-survey and post-survey. The survey consisted of multiple-choice type-A and type-X questions, and three unipolar Likert scales questions allowing the respondent to state their confidence in using their knowledge of symptoms, coordinating care and starting treatment. After the lecture and simulation, the staff retook the initial survey as described above.


Of the 12 symptoms of LAST tested on the pre-surveys and post-surveys, 9 symptoms had an increased percentage of correct identifications with the symptoms of muscle twitching, hypotension and sinus bradycardia having a decreased percentage of correct identification (online supplemental figures 1,2). An increase from roughly 33% to 100% of individuals correctly identified the correct dosage of 20% lipid emulsion (online supplemental figure 3). There were increased numbers of correct responses for steps in treatment, specific treatment measures, necessary equipment and equipment locations. Survey responders also reported higher confidence in symptom recognition, starting treatment and coordinating care after interventions (figure 1). In addition, the vast majority (>90%) of staff felt an improvement in their ability to recognise and manage LAST compared with before the didactic session and simulation exercise (figure 2).

Supplemental material

Figure 1

LAST recognition and management confidence. On a scale of 1–100 (1 meaning no confidence and 100 meaning full confidence), participants described their confidence in recognising symptoms of last, starting treatment and coordinating care. All tasks showed an increase in confidence of ~20–30 points after the didactic session and simulation exercise. LAST, local anaesthetic systemic toxicity.

Figure 2

Global effect of change. Greater than 90% of participants felt improvement in their ability to recognise and manage last after the didactic session and simulation exercise, compared with before.


The LAST interactive lecture and simulation was a model of healthcare team multidisciplinary collaboration. This educational series provided physicians the platform to not only educate but also to collaborate with their staff and team members in a professional setting. This activity helped to increase knowledge, strengthen relationships and build trust among pain clinic procedural staff members, which was reflected in the results. Through the presurvey and postsurvey, we were able to objectively demonstrate that the education regarding LAST identification and management was significantly successful for the ancillary staff members at our clinic.

Given the increase in outpatient procedures across medicine, which has largely been made possible using regional techniques requiring local anaesthetics, it is not only important for physicians and ancillary staff in the chronic pain clinical environment to understand the most lethal complication of using local anaesthetics, but also physicians and staff that work in ambulatory surgery centres. As anaesthetic and surgical techniques become more effective and less invasive, the need for prolonged hospital courses and the overuse of expensive in-patient healthcare has progressively declined. With this changing healthcare landscape, the education of physicians and ancillary staff is also changing. Our study demonstrated an effective way to educate physicians and other healthcare team members. Although this pilot study was limited to one institution and to one department, we believe that interprofessional educational sessions such as this, offer unique learning opportunities for any provider who works in settings using frequent local anaesthetic administration. Overall, this is a valuable interactive lecture and simulation experience for learners who have access to a simulation centre. However, this exercise may be modified to the lecture series and an alternative medium, such as a virtual video module, to provide a more cost-effective experience.

Required materials

Simulation environment with high-fidelity manikin, classroom and debriefing room.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


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  • Contributors RA contributed to conceptualisation, data curation, formal analysis, methodology, writing, guarantor, editing and review of the manuscript. MR contributed to conceptualisation, data curation, formal analysis, methodology, writing, editing and review of the manuscript. MFA contributed to conceptualisation, data curation, formal analysis, methodology, writing, editing and review of the manuscript. DM contributed to conceptualisation, data curation, formal analysis, methodology, writing, editing and review of the manuscript. KV contributed to conceptualisation, data curation, formal analysis, methodology, supervision, validation, writing, editing and review of the manuscript. AU contributed to conceptualisation, data curation and methodology. PY contributed to conceptualisation, data curation, formal analysis, methodology, supervision, validation, writing, editing and review of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.