• Overdose of local anaesthetic during a surgical procedure is a potentially fatal event
• This guideline applies to the process of administering LA for surgical infiltration by non-anaesthetists
• It is important to use a standardized approach for local anaesthetic infiltration within theatres to reduce this risk
• Key check points in the process are designed to ensure the correct drug and dose is administered

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• This guideline aims to prevent overdose of local anaesthetic (LA) during surgical infiltration
• A standardized approach to LA infiltration within theatres is encouraged
• Best practice recommendations are from the Royal College of Anaesthetists (RCoA) and the British Orthopaedic Association (BOA), which were produced in response to the 2024 Coroner’s Report on LA toxicity

• This guideline applies to the process of administering LA for surgical infiltration by non-anaesthetists
• This guideline does not apply to situations where LA is injected by anaesthetists

• There are a variety of LA drugs available, the choice of which is at the discretion of the responsible clinician

Maximum recommended dose of commonly used LAs:

Use lean body weight in patients living with obesity

• LA used in a peripheral nerve block should ideally be the same drug as any planned LA for surgical infiltration – this will help with total dose calculation
• Where further surgical infiltration is not anticipated, any choice of LA can be used for a peripheral nerve block
• In the event of surgical infiltration with a different LA drug to that used in a peripheral nerve block, the percentage of the maximum dose should be calculated for each drug and the remaining dose be used for surgical infiltration (for e.g. if 50% of Ropivacaine 3mg/kg maximum dose was used for the peripheral nerve block, if Bupivacaine is used for surgical LA infiltration, then up to 50% of the maximum dose of 2mg/kg can be used)
• Note: consider any prior administration of LA, for example, in a Fascia Iliaca Block performed in the Emergency Department. Ensure LA dose does not exceed 24 hour maximum – for Bupivacaine and Levobupivacaine this is 400mg / 24h

For Lower Limb Joint Replacements

• Use GIRFT protocol with LA infiltration guide
  • Local Anaesthesia for Total Hip Replacement
  • Local Anaesthesia for Total Knee Replacement
• Levobupivacaine 0.125% (1.25 mg/ml): Presented in 200 ml bags. Combined with 1 ml of 1:1000 adrenaline per 200 ml to achieve 5 microgram/ml adrenaline concentration
• Use premixed LA where possible to minimize dosing errors

Team Brief

• All theatre staff must be present when anaesthetist and surgeon discuss the planned use of LA for the operating list

Before LA preparation by surgical scrub / practitioner

• Confirm:
  • LA drug, total dose (in mg), concentration (mg/ml), and volume (ml)
• Adjust for any changes in anaesthetic dose given
• Record details on the theatre whiteboard

Drug Preparation

• Drawing up of LA must be conducted by a theatre nurse and verified by the scrub nurse

Pre-infiltration Pause

• Mandatory pause before infiltration for all team members to verify:
  • Correct drug
  • Correct concentration
  • Correct volume
• Prior to LIA, the surgeon will check the drug ampoules/bag, including dilution fluid used and expiry date

• The responsible clinician administering the LA should prescribe and sign for the drug administration on the MAR on Epic