Reactions 1356 - 18 Jun 2011

Bupivacaine/fentanyl/levobupivacaine

Harlequin appearance in a child: case reportHarlequin appearance developed in a 6-year-old girl after

epidural analgesia with levobupivacaine, bupivacaine andfentanyl.

The girl required surgery for a left-sided empyema, andunderwent tracheostomy and decortication under generalanaesthesia. A thoracic epidural was inserted, and sheremained in a right lateral position for the duration of the3-hour procedure. Intraoperatively, she received a total of0.25% levobupivacaine 16mL (administeredincrementally); an infusion with a 1mL bolus followed by3.3 mL/h of 0.1% bupivacaine with 2 µg/mL fentanyl wasstarted 1 hour before surgery completion. She also receivedparacetamol [acetaminophen] and clonidine. Herimmediate postoperative period was unremarkable, butpronounced flushing developed 10 minutes after her returnto the ward. Flushing was restricted to the left side of herface and spared the forehead. On assessment, a denseblock up to T3 was evident on her right side, but the nerveblock was less pronounced on her left side.

The girl was repositioned. The epidural block evened outbetween the two sides, and her harlequin appearanceresolved within the subsequent 12 hours.

Author comment: "In our case, it seems likely thatprolonged right lateral positioning during surgery led to anasymmetrical high epidural block leading to ipsilateralsympathetic outflow disruption presenting as right-sided facialpallor with leftsided flushing."Cooper S, et al. Harlequin appearance postepidural analgesia in a child followingthoracotomy. Pediatric Anesthesia 20: 959-60, No. 10, Oct 2010. Available from:URL: http://dx.doi.org/10.1111/j.1460-9592.2010.03383.x - UnitedKingdom 803055700

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Reactions 18 Jun 2011 No. 13560114-9954/10/1356-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved