Reactions 1364 - 13 Aug 2011

SBupivacaine

Heart arrest following epidural administration:case report

A 59-year-old woman developed heart arrest followingepidural administration of bupivacaine.

The woman, whose history included pulmonary arterialhypertension, was diagnosed with a nonfunctioningadrenal tumour and underwent a laparoscopic-assistedadrenalectomy. Following insertion of a thoracic epidural atthe T6–7 level, she received 3 + 7mL of 0.25% bupivacaineas a test dose. She then received propofol, atracuriumbesilate and remifentanil as general anaesthesia and wasintubated. Remifentanil and isoflurane were administeredas anaesthetic maintenance. After 4 hours, near the end ofsurgery, she received 10mL of 0.25% bupivacaine as anepidural bolus of local anaesthetic. The neuromuscularblock was reversed with glycopyrrolate and neostigmine.She subsequently developed bradycardia and hypotension,followed by asystolic heart arrest [time to reaction onsetnot stated].

One cycle of CPR was performed, and the womanreceived epinephrine [adrenaline] and atropine.Spontaneous circulation returned; however, she had anarterial pressure of 72/33mm Hg and pulmonary oedema,with an arterial oxygen saturation of 71% on ventilationwith 100% oxygen. Epinephrine and norepinephrine[noradrenaline] were administered, and her conditionshowed gradual improvement. Transthoracicechocardiography revealed right ventricular dilatation andimpaired function. ECG showed sinus rhythm with left axisdeviation and an intraventricular conduction defect. Shewas transferred to an ICU. After approximately 2 days ofventilation, she was extubated with no neurologicaldeficits. She was subsequently discharged on cardiac andpulmonary hypertension follow-up.

Author comment: "In our patient, we think that the bolusdose of local anaesthetic epidurally would have impaired thecardiac sympathetic response . . . thereby causinghaemodynamic collapse and cardiac arrest."Subash G, et al. Perioperative cardiac arrest after thoracic epidural analgesia in apatient with increased pulmonary artery pressure. British Journal of Anaesthesia107: 108-109, No. 1, Jul 2011. Available from: URL: http://dx.doi.org/10.1093/bja/aer182 - United Kingdom 803058473

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Reactions 13 Aug 2011 No. 13640114-9954/10/1364-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved