Intralipid Dosing for LAST – Arun Anaesthesia Academy

As per ASRA guidelines (LAST checklist 2020)

Emergency protocol — LAST

Call for help immediately. Stop LA injection. Airway management first. Start CPR if cardiac arrest. Administer 20% Intralipid as per calculated doses below.

Demographics

Lipid emulsion is dosed on lean body weight. Enter height for an accurate calculation — if left blank, total body weight will be used instead.

Male

Female

Height should be 100–230 cm and weight 1–250 kg.

Enter patient height and weight above to calculate lipid emulsion doses.

Steps

Full Protocol

Treatment Steps (20% Intralipid)

Concurrent Emergency Management

A

Airway & oxygenation

100% O₂ via face mask. If unconscious — intubate. Hyperventilate to correct acidosis (CO₂ target 35 mmHg). Avoid hypoxia and acidosis as they worsen cardiotoxicity.
B

Seizure control

Benzodiazepines preferred (midazolam 0.05–0.1 mg/kg IV). Avoid propofol in haemodynamic compromise. Avoid thiopentone (large doses cause cardiovascular depression). Propofol only in small incremental doses if no alternative. Refractory seizures — intubate and give neuromuscular blockade with continued sedation.
C

Cardiac arrest — CPR

Standard ACLS. Avoid vasopressin, calcium channel blockers, beta-blockers. Use adrenaline in reduced doses (<1 mcg/kg). Amiodarone preferred for arrhythmias. Sodium bicarbonate is reasonable for life-threatening wide-complex tachycardia (AHA 2025). Be prepared for prolonged resuscitation — lipid takes time to work.
D

ECMO / cardiopulmonary bypass

Consider early if refractory cardiac arrest despite lipid therapy and standard ACLS. VA-ECMO is reasonable for LAST cardiogenic shock refractory to drug treatment, in adults and children (AHA 2025). Contact cardiac surgery / ECMO centre early in severe cases.
E

Report to LAST registry

Report all LAST cases to the AAGBI Lipid Rescue website: www.lipidrescue.org

Lipid Emulsion — Side Effects

RespiratoryBronchospasm, breathlessness
MetabolicLipaemia, severe hypertriglyceridaemia, pancreatitis, fat overload
LaboratoryRaised amylase. Interferes with blood tests — haemoglobin, methaemoglobin, electrolytes, base excess, liver enzymes, lactate
CircuitsMay interfere with ECMO circuits and renal replacement therapy
OtherAllergic reactions, nausea and vomiting, chest pain

Sources: NYSORA; StatPearls — Local Anesthetic Toxicity

Differential Diagnosis

AnaphylaxisBronchospasm, angioedema, urticaria, flushing
High neuraxial blockAscending sensory and motor block — without the neurological excitation of LAST
MethaemoglobinaemiaAfter prilocaine or benzocaine — cyanosis and hypoxaemia out of proportion to respiratory findings
OthersVasovagal reaction, hypoglycaemia, stroke

Source: StatPearls — Local Anesthetic Toxicity

Demographics

Treatment Steps (20% Intralipid)

Full LAST Protocol Summary

Concurrent Emergency Management

Total Dose Administered

Lipid Emulsion — Side Effects

Differential Diagnosis