Reactions 1274 - 17 Oct 2009

SBupivacaine

Systemic toxicity treated with soya oil emulsion:case report

A 17-year-old boy developed bupivacaine systemictoxicity including seizure and ventricular fibrillation.Subsequent treatment including soya oil emulsion[Intralipid] was successful.

The boy presented for repair of a ruptured patellofemoralligament using single-shot femoral nerve block forpostoperative anaesthesia. He was sedated withmidazolam and fentanyl. The femoral nerve was thenlocated and 0.5% bupivacaine was injected in 5mLincremental injections for a total of 20mL over 2–3 minutes.He began seizing as the needle was withdrawn, and apresumptive diagnosis of bupivacaine systemic toxicity wasmade.

The boy was immediately started on bag-maskventilation and received IV midazolam. Within 1 or2 minutes of seizure onset, other anaesthesiologists arrivedand immediately began 20% soya oil emulsionadministration. His ECG showed no electrical activity, but itwas soon discovered that an ECG lead had becomedetached; however, his pulses were absent, and CPR wasimmediately initiated. The displaced ECG lead wasreattached and ventricular fibrillation was diagnosed. Thediagnosis was confirmed after attaching an automaticelectronic defibrillator, which administered one electricalcountershock. His cardiac rhythm converted to narrowcomplex sinus tachycardia with a BP of 183/83mm Hg andbounding pulses. He received 500mL of soy oil emulsion20% during resuscitation and a significant, but unknown,quantity before intubation. Once stable he was transferredto a near by hospital. There was no evidence of cardiac orcerebral sequelae during follow-up.

Author comment: "[W]e have presented a case ofbupivacaine systemic toxicity in which successful resuscitationmay have been aided by the very early administration of lipidemulsion, in conjunction with effective CPR."Markowitz S, et al. Immediate lipid emulsion therapy in the successful treatment ofbupivacaine systemic toxicity. Regional Anesthesia and Pain Medicine 34: 276,No. 3, May-Jun 2009 - USA 801154140

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Reactions 17 Oct 2009 No. 12740114-9954/10/1274-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved