Reactions 1252 - 16 May 2009

SBupivacaine

Cardiotoxicity following accidental intravascularadministration: case report

A 33-year-old man developed cardiotoxicity followingaccidental intravascular injection of bupivacaine duringperformance of a brachial block for surgery.

The man presented for debridement of a compoundfracture of the humerus. Following a single-injectioninfraclavicular paracoracoid block using 0.375%bupivacaine 30mL, given over 3 minutes with aspiration at5mL intervals, he abruptly reported the onset of a drysensation in his eyes and throat.

The injection was immediately stopped. The manimmediately developed seizures and apnoea, andventilatory support was started. He received soya oilemulsion within 30 seconds of seizure onset and theseizures stopped after thiopental sodium was given. AnECG trace then showed a narrow complex tachycardiawhich peaked at 160 beats/minute. Over 90 seconds, thetachycardia was followed by a broadening of QRScomplexes, slowing of the heart, and asystole. Heunderwent cardiopulmonary resuscitation and trachealintubation, and received epinephrine [adrenaline]. Overthe 30 minutes following return of spontaneous circulation,further soya oil emulsion was infused and his heart rate andrhythm reverted to sinus tachycardia (110 beats/minute).Circulation was supported with an epinephrine infusion.He remained haemodynamically stable so it was decided toproceed with surgery. After surgery, and approximately40 minutes following completion of the soya oil emulsioninfusion, a progressively accelerating sinus tachycardia(140 beats/minute), accompanied by frequent multifocalventricular extrasystoles and short, self-terminating runs ofventricular tachycardia were observed. This was presumedto be the recurrence of bupivacaine cardiotoxicity. Nofurther soya oil emulsion was available, so he receivedamiodarone and was subsequently admitted to the ICU.His arrhythmias stopped and inotropic support wasdiscontinued. On the first postarrest day, total creatinekinase of 2378 IU/L, MB fraction 26 µg/L and troponin I of1.255 µg/L suggested that he had experienced myocardialdamage. Four days later, his cardiac enzymes haddecreased and he was discharged [patient outcome notstated].

Author comment: "[W]e report a case of recurrentsystemic local anesthetic toxicity after successful treatmentwith lipid emulsion".Marwick PC, et al. Recurrence of cardiotoxicity after lipid rescue frombupivacaine-induced cardiac arrest. Anesthesia and Analgesia 108: 1344-1346, No.4, Apr 2009 - South Africa 801141351

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Reactions 16 May 2009 No. 12520114-9954/10/1252-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved