Reactions 688 - 14 Feb 1998

SBupivacaine

Ventricular arrhythmias: case reportA 16-year-old girl with an 8-year history of isovaleric

acidaemia, who was undergoing bilateral axillary liposuction,experienced an intraoperative episode of severe ventriculardysrhythmias after she was given a SC injection of tumescencesolution containing bupivacaine.

General anaesthesia was induced uneventfully, and thepatient then received 300ml of tumescent solution containing22mg of bupivacaine and 300µg of epinephrine [adrenaline] inlactated Ringer’s solution injected subcutaneously in the rightaxilla. Four minutes later, the girl’s ECG changed to a widecomplex ventricular dysrhythmia at 20 beats/min. Her BPdecreased from 130/70 to 60/40mm Hg.

Inhaled anesthetics were withheld and the patient received100% oxygen, and IV ephedrine. Her ECG then showedventricular tachycardia at 160 beats/min. Her end-tidal carbondioxide concentration decreased to 18mm Hg and her HR wasbarely discernible. She was given IV lidocaine and epinephrineand her ECG converted to a sinus tachycardia of 150beats/min, with a BP of 120/80mm Hg. The operativeprocedure was cancelled.

Postoperatively, the patient’s ECG showed a prolonged QTinterval and her echocardiogram showed mild left ventriculardysfunction. Her plasma free carnitine level was 32µM(normal > 20), although 6 weeks prior to surgery it was only7.8µM. One week later, the girl’s ECG showed a normal QTinterval.

Author comment: ‘We suspect that intravascular absorptionof the small dose of bupivacaine (22mg) led to acutebupivacaine toxicity as manifested by initial ECG changesfollowed by vital sign changes.’ Patients with adult-onsetisovaleric acidaemia may be more susceptible to the toxiceffects of bupivacaine.Weinberg GL, et al. Malignant ventricular dysrhythmias in a patient with isovalericacidemia receiving general and local anesthesia for suction lipectomy. Journal ofClinical Anesthesia 9: 668-670, Dec 1997 - USA 800635006

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Reactions 14 Feb 1998 No. 6880114-9954/10/0688-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved