Which local anesthetic should be avoided in patients with significant liver impairment?

Lidocaine should be avoided in patients with significant liver impairment due to its metabolism primarily occurring in the liver. When the liver function is compromised, there is a risk of accumulating lidocaine in the body, which can lead to increased toxicity and side effects. This includes the potential for central nervous system and cardiovascular complications.

In contrast, other local anesthetics, such as articaine, bupivacaine, and mepivacaine, may have alternative metabolic pathways or shorter half-lives that make them somewhat safer options in individuals with liver limitations. For instance, articaine is metabolized both in the liver and by ester hydrolysis, while bupivacaine and mepivacaine are also metabolized by the liver but might be tolerated better depending on the degree of liver impairment and the specifics of patient health.