Reactions 1339 - 19 Feb 2011

SBupivacaine/lidocaine/ropivacaine

Unconsciousness and generalised tonic seizure:2 case reports

A 62-year-old man and a 73-year-old womanexperienced symptoms of anaesthetic toxicity(unconsciousness and seizure, respectively) duringinterscalene nerve block with lidocaine combined witheither bupivacaine or ropivacaine [not all routes stated; notall indications stated].

The man was scheduled for surgical decompression ofthe left shoulder joint. He received fentanyl, midazolam,propofol and oxygen; 1% lidocaine 3mL was thenadministered for local anaesthesia, and he underwent leftinterscalene block with injection of 1% lidocaine 30mL and0.25% bupivacaine 20mL. After nerve block, 2% lidocaine40mg, propofol, fentanyl and vecuronium bromide wereadministered, and he was intubated. Anaesthesia wasmaintained with fentanyl and propofol until 15 minutesbefore the end of surgery, and a continuous infusion of0.25% bupivacaine 2mL/h via an epidural catheter wasinitiated. Surgery was completed after 50 minutes, and hereceived atropine and neostigmine, but did not awake orbreathe spontaneously. Naloxone was administered, but heremained deeply anaesthetised 30 minutes later, and hispupils were unreactive and dilated at 5mm. He wastransferred to an ICU and ventilated, and received dextranand glucose infusions. He became conscious 30 minutesafter ICU admission (3 hours after the nerve block); hebreathed spontaneously and responded to verbalcommands, and was extubated. His pupils constricted to2.5mm and became reactive 30 minutes later. He wasasymptomatic 24 hours later and was discharged.

The woman was scheduled to undergo surgical shoulderligament suture. She received midazolam, fentanyl,flurbiprofen, propofol and oxygen, and then underwentlocal anaesthesia with 1% lidocaine 3mL. Interscalene blockwas performed with injection of 1% lidocaine 15mL with0.75% ropivacaine 15mL via the cannula; a catheter wassubsequently inserted and the cannula was removed. Sheexperienced a generalised tonic seizure 7–8 minutes aftercatheter insertion. She immediately received propofol,fentanyl, midazolam and vecuronium bromide, and wasintubated. Her seizure resolved after 2 minutes. Surgerywas maintained with nitrous oxide and propofol, and lastedfor 95 minutes. After the operation, she received atropine,neostigmine, flumazenil and naloxone. She awoke, wasextubated and began receiving a 0.2% ropivacaine 2 mL/hinfusion through the interscalene catheter for analgesia. Nofurther complications were encountered.

Author comment: "The case 1 showed toxicity withbupivacaine 50 mg and case 2 with ropivacaine112.5 mg. . . Lidocaine was combined in both cases to fastenthe onset of analgesia. Lidocaine might also induce toxiceffects. . . We reported two cases of local anesthetic toxicityby interscalene block with lidocaine and bupivacaine or withropivacaine, one lost consciousness and the other developedseizure."Nishiyama T, et al. Local anesthetic toxicity in interscalene block: Clinical series.Minerva Anestesiologica 76: 1088-1090, No. 12, Dec 2010 - Japan 803049495

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Reactions 19 Feb 2011 No. 13390114-9954/10/1339-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved