Local anaesthetics are essential to regional anaesthesia but may exert neurotoxic effects on peripheral nerves under specific conditions. Although perioperative nerve injury is increasingly recognised, the contribution of local-anaesthetic neurotoxicity, the relative toxicity of different agents and concentrations, and the influence of patient-related risk factors remain incompletely defined. This evidence-based narrative review synthesises experimental and clinical data on peripheral nerve neurotoxicity associated with local anaesthetics and discusses implications for clinical practice and future research. A prospectively registered search was conducted across major biomedical databases for studies published between 1990 and 2024. Experimental evidence consistently demonstrates dose-dependent and time-dependent neurotoxicity for all clinically used local anaesthetics, characterised by ultrastructural damage, oxidative stress, mitochondrial dysfunction and activation of apoptotic and intracellular signalling pathways. Relative toxicity varies between agents and concentrations, with lidocaine and bupivacaine often appearing more potent than ropivacaine or chloroprocaine in preclinical models, while findings for articaine remain heterogeneous. Diabetic and metabolically compromised nerves exhibit increased susceptibility, supporting a 'two-hit' model of injury. In contrast, clinical evidence directly linking specific agents, concentrations or exposure durations to permanent peripheral nerve injury is limited, and such injuries are typically multifactorial. Overall, chemical neurotoxicity should be considered one component of a broader perioperative risk profile. Risk mitigation should prioritise avoidance of intraneural injection, adherence to recommended doses and cautious use of high concentrations or prolonged exposure, particularly in vulnerable nerves. Further research should integrate mechanistic and clinical outcomes while accounting for patient-level risk factors.

Due to the continued use of fossil fuels and other chemical pollutants, atmospheric greenhouse gas concentrations and environmental pollution continue to rise. The health sector is both a driver and a victim of these developments, and intensive care medicine (ICM), with its high energy demands, extensive use of disposable products, and large variety of pharmaceuticals, contributes substantially to the climate crisis and environmental degradation. The European Society of Anaesthesiology and Intensive Care (ESAIC) therefore aimed to develop consensus recommendations to reduce the environmental footprint of ICM across Europe. A total of 37 recommendations were initially drafted by four topic groups (1) energy, (2) waste management, (3) medication, and (4) ethics-each composed of three to five experts. To facilitate implementation in both middle- and high-income European countries, the agreement threshold was set at 80%. The recommendations were validated by 37 experts from 20 countries using a two-step Delphi procedure. In the first round, all recommendations reached at least 75% agreement. After amendments to four recommendations based on expert feedback, all achieved over 80% approval in the second round, with 32 receiving more than 90% agreement. The final recommendations address: (1) a complete transition to renewable energy and implementation of energy-saving strategies; (2) optimisation of procurement in clinical processes (10Rs) and waste management solutions for single-use plastics; (3) reduction of greenhouse gas emissions (mainly fluorinated gases) and water toxicity caused by medications, as well as prevention of a further increase in antimicrobial resistance (AMR); and (4) implementation of an environment-related, ethically guided precautionary principle. This ESAIC consensus provides a practical framework for sustainable ICM. Stakeholders at all levels should now introduce these recommendations through institutional policies, procurement criteria, guidelines and quality improvement programmes to align intensive care practice with planetary health goals.