Reactions 1291 - 6 Mar 2010

SBupivacaine/lidocaine

CNS and heart disorders treated with soya oilemulsion: case report

A 36-year-old man developed CNS and heart disordersincluding headache, dizziness, diplopia, tachycardia,hypertension and ST segment depression following lidocaineand bupivacaine injection. Subsequent treatment with soya oilemulsion [Intralipid] was successful.

The man had a history of chronic leg pain, femoral-poplitealdeep vein thrombosis, lower limb compartment syndrome andpainful spasms of his leg. He had undergone fasciotomy andmyomectomy of his gastrocnemius, and surgicaldecompression and neurolysis of his popliteal nerve. He wasadmitted with intractable pain and spasm of his right lower leginvolving virtually all groups of muscles innervated by thecommon fibular and tibial nerves. The spasms proved resistantto lidocaine, benzodiazepines and opioid infusions. Over thesubsequent 3 weeks, he received regular intramuscular localanaesthetic injections, intramuscular botulinum toxin Ainjections, several nerve blocks, epidural infusions, selectivephenol nerve ablations, and finally radiofrequency ablations ofthe tibial and common fibular nerves. On one occasion, amixture of 10mL of 1% lidocaine (with epinephrine[adrenaline] 1:200 000) and 20mL of 0.5% bupivacaine wereinjected into his soleus and extensor hallucis longus musclesfor pain and spasm relief. Within 60 seconds of administration,he developed perioral tingling, dizziness, headache, lightheadedness and diplopia, which were quickly followed by anHR of 153 beats/minute, a BP of 180/110mm Hg, and STsegment depression in the anterior and lateral chest leads onhis ECG. The rapid onset of symptoms led to the suspicion oflocal anaesthetic toxicity.

The man received Hartmann’s solution and oxygen. Within5 minutes, he received two boluses of 20% soy oil emulsion,with each bolus lasting 1–3 minutes. Within the first minute ofsoya oil emulsion administration, his symptoms dramaticallyimproved, and his HR and BP decreased to 92 beats/minuteand 158/105mm Hg, respectively. His diplopia, headache andfaintness also subsided quickly. He received an addition100mL soya oil emulsion infusion over 1 hour, and wasadmitted to the intensive care unit (ICU). Repeat ECG ondischarge from the ICU showed complete reversal of the STsegment change.

Author comment: "A few human case reports now existdemonstrating use of Intralipid 20% where local anesthetic(LA) has caused central nervous system toxicity. We wouldlike to add a case to the literature regarding the successfuluse of Intralipid in the treatment of LA-induced centralnervous system toxicity."Espinet AJ, et al. The successful use of intralipid for treatment of local anesthetic-induced central nervous system toxicity: Some considerations for administration ofintralipid in an emergency. Clinical Journal of Pain 25: 808-809, No. 9, Nov-Dec2009. Available from: URL: http://dx.doi.org/10.1097/AJP.0b013e3181af739e -Australia 803007109

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Reactions 6 Mar 2010 No. 12910114-9954/10/1291-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved