Reactions 1200 - 3 May 2008

SBupivacaine/mepivacaine

Cardiovascular collapse and respiratoryinsufficiency, treated with soya oil emulsion: casereport

A 60-year-old man, who had a history of coronary arterydisease and myocardial infarction, experienced cardiovascularcollapse and respiratory insufficiency following localanaesthesia with bupivacaine and mepivacaine; he wassuccessfully treated with IV soya oil emulsion.

The man presented for revision of a basilic vein fistula on hisarm. After administration of midazolam, he underwent single-injection supraclavicular brachial plexus block. Over severalminutes, local anaesthetics with 1:200 000 epinephrine wereinjected (1.5% mepivacaine 30mL with sodium bicarbonate,followed by 0.5% bupivacaine 10mL, in separate 10mLsyringes). His vital signs were initially stable but, 5 minutesafter his last anaesthetic injection, his respiration becamelaboured with bilateral breath sounds. His conditionprogressed to apnoea, unresponsiveness and pulselessness.

Cardiopulmonary resuscitation (CPR) was started, but theman’s heart rhythm deteriorated to ventricular fibrillation at8 minutes, and torsade de pointes at 9 minutes. Administrationof atropine, epinephrine [adrenaline], vasopressin, sodiumbicarbonate and magnesium sulfate, in addition todefibrillation did not restore sustained cardiovascular activity.Ten minutes after CPR initiation, a central IV infusion of 20%soya oil emulsion [Liposyn III] was begun; over 30 minutes,250mL were infused. His unbound bupivacaine concentrationwas determined as 0.49 µg/mL after 2 minutes of the infusion.He eventually became haemodynamically stable and startedbreathing spontaneously. He was transferred to an ICU and,2 hours later, the desired nerve block of his left arm wasachieved. He was discharged 3 days later.

Author comment: "[W]e cannot exclude the possiblesynergistic contribution of mepivacaine to this cardiac event."Warren JA, et al. Intravenous lipid infusion in the successful resuscitation of localanesthetic-induced cardiovascular collapse after supraclavicular brachial plexusblock. Anesthesia and Analgesia 106: 1578-1580, No. 5, May 2008 -USA 801080640

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Reactions 3 May 2008 No. 12000114-9954/10/1200-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved