Local Anesthetic Systemic Toxicity Following High-Volume Ropivacaine, Epinephrine, Clonidine, and Ketorolac (RECK) Infiltration During Total Knee Arthroplasty: A Case Report

Local infiltration analgesia is widely used for post-operative pain control following joint arthroplasty and is generally considered to carry a low risk of local anesthetic systemic toxicity.We report a case of local anesthetic systemic toxicity in a 72-year-old woman following primary total knee arthroplasty performed under spinal anesthesia with adjunctive adductor canal block and high-volume periarticular infiltration with ropivacaine, epinephrine, clonidine, and ketorolac (RECK) solution.The cumulative perioperative ropivacaine dose was 286 mg (3.9 mg/kg).Soon after arrival in the post-anesthesia care unit, the patient developed acute confusion and focal myoclonic activity in the right arm without cardiovascular instability.Lipid emulsion was administered with rapid and complete neurological recovery.This case highlights the importance of considering cumulative dosing across regional and surgical infiltration techniques, the influence of patient-specific factors on susceptibility to toxicity, and the need for vigilance for delayed manifestations of local anesthetic systemic toxicity following high-volume infiltration.