Reactions 1151 - 12 May 2007

SLevobupivacaine

Tonic-clonic seizures and cardiovascular collapsetreated with soya oil emulsion in an elderly patient:case report

A 75-year-old woman with chronic severe obstructivepulmonary disease, who was undergoing repair of a femurfracture, developed tonic-clonic seizures and cardiovascularcollapse after receiving levobupivacaine for lumbar plexusblock.

The woman, whose ECG showed frequent atrial ectopicsand pathological q waves in V1-V3 at baseline, received a slowinjection of 0.5% levobupivacaine 20mL into the psoas muscleat L4 level. She ‘groaned’ and became unresponsive withinseconds. She was placed in supine position and instantly had atonic-clonic seizure that lasted for several seconds.

The woman received airway support and oxygen via a facemask. A presumptive diagnosis of local anaesthetic toxicityfrom IV injection was made and soya oil emulsion [Intralipid]was requested. Her arterial BP was 60/40mm Hg; altered QRSmorphology with reducing QRS voltage and broadening QRScomplexes were observed on ECG. Her radial pulse was notpalpable. She had a second seizure about 2 minutes after thefirst; her appearance was ‘mottled’ and venous-congested,and she was cold to the touch. Her QRS morphologydeteriorated and the complexes became difficult todifferentiate from background ECG noise. She received IVmetaraminol, propofol and suxamethonium chloride[succinylcholine chloride]. She was intubated and, within4 minutes of the levobupivacaine injection, 100mL of the 20%soya oil emulsion were administered through the peripheralcannula over 5 minutes. Her arterial BP was 90/60mm Hg andher QRS morphology rapidly normalised during the infusion.Propofol was administered and, since her BP, HR and ECGwere stable for 10 minutes following the infusion, surgeryproceeded. She regained consciousness 2 hours later. Onrepeat ECG, no changes from baseline were observed. Sheremained stable and orientated, was transferred to anorthopedic ward and had an uneventful recovery.

Author comment: "In this case, there was a rapid loss ofconsciousness followed by two seizures immediately afterinjection of levobupivacaine. This strongly suggests theintravascular administration of levobupivacaine."Foxall G, et al. Levobupivacaine-induced seizures and cardiovascular collapsetreated with Intralipid (Rm). Anaesthesia 62: 516-518, No. 5, May 2007 - UnitedKingdom 801071342

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Reactions 12 May 2007 No. 11510114-9954/10/1151-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved