Reactions 1365 - 20 Aug 2011

SBupivacaine

Severe junctional bradycardia in an elderlypatient, treated with soya oil emulsion: casereport

A 69-year-old woman developed severe junctionalbradycardia after receiving bupivacaine for localanaesthesia. The condition was reversed followingadministration of soya oil emulsion.

The woman, who had end-stage renal disease anduraemia, had been scheduled for carpal tunnel surgeryfollowing ultrasound-guided infraclavicular brachial plexusblock. She received 1.5% lidocaine 15mL, followed by0.375% bupivacaine 10mL. With repeated negativeaspiration tests, the anaesthetic solution was given inboluses of 3-4mL over several minutes. With the blocksuccessfully completed, she was transferred to theoperating room. Whilst being attached to the monitoringdevices, she suddenly became obtunded and unresponsive[time to reaction onset not clearly stated]. ECG showedsevere junctional bradycardia with a ventricular rate of30 beats/min (bpm). Arterial blood gas analysis showedmetabolic acidosis; this was corrected with sodiumbicarbonate. Her bradycardia persisted despite severaldoses of atropine and ephedrine.

Suspected of having local anaesthetic-inducedcardiotoxicity, the woman received IV soya oil emulsion.After 2 minutes, her ECG pattern changed to regular sinusrhythm with first-degree AV block, with a ventricular rate of40bpm. Her consciousness returned slowly. The scheduledprocedure was cancelled. Her consciousness cleared andher haemodynamic status remained stable. Her heart ratereturned to baseline 90 minutes after anaesthesia. She wasdischarged the following day with no furthercomplications.

Author comment: "Considering that lidocaine’s dose usedin our case was relatively lower in cardiodepressant effect(lidocaine 225 mg vs. bupivacaine 37.5 mg), it could be morerational to attribute the conductive depression in this patientto bupivacaine rather than to lidocaine, even with or withoutlidocaine’s synergistic or additive effect."Shih Y-H, et al. Successful reversal of bupivacaine and lidocaine-induced severejunctional bradycardia by lipid emulsion following infraclavicular brachial plexusblock in a uremic patient. Acta Anaesthesiologica Taiwanica 49: 72-74, No. 2, Jun2011. Available from: URL: http://dx.doi.org/10.1016/j.aat.2011.05.005 -Taiwan 803059174

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Reactions 20 Aug 2011 No. 13650114-9954/10/1365-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved