Reactions 1504, p18 - 7 Jun 2014

O SLevobupivacaine/ropivacaine

Generalised tonic-clonic seizures: 2 case reportsTwo women developed generalised tonic-clonic seizures

after receiving bilateral transversus abdominis plane blocks forpostoperative analgesia with levobupivacaine and ropivacaine,respectively. In one woman, partial unintentional IM injectionof levobupivacaine occurred, while the other woman receivedan overdose of ropivacaine.

A 36-year-old woman underwent caesarean section underspinal anaesthesia at 39 weeks’ gestation. At the end ofsurgery, an ultrasound-guided transversus abdominis planeblock was performed, with bilateral injection of 20mL oflevobupivacaine 3.75 mg/mL (total dose 150mg, 2.68 mg/kg).While the procedure was uneventful, some of the injectionmay have been administered intramuscularly. Ten minuteslater, she became unresponsive, and experienced ageneralised tonic-clonic seizure that self-terminated within1 minute. Bag-mask ventilation was required due to persistentapnoea and peripheral cyanosis, and she received lipidemulsion. Spontaneous breathing subsequently returned;however, she experienced another seizure. Lipid emulsion wascontinued, and she received clonazepam. Her seizures thenstopped and she gradually recovered. She was discharged onthe third postoperative day.

A 33-year-old woman with a twin pregnancy underwentcaesarean section at 36 weeks and 4 days’ gestation. At theend of the procedure, she received an ultrasound-guidedtransversus abdominis plane block with bilateral injection of20mL of ropivacaine 7.5 mg/mL (total dose 300mg,4.9 mg/kg). A generalised tonic-clonic seizure occurred25 minutes later, which self-terminated within 20 seconds.Immediate resuscitation with bag-mask ventilation wasrequired, and she received lipid emulsion. Spontaneousbreathing and full consciousness subsequently recovered.Tests showed plasma concentrations of ropivacaine were3.99 µg/mL and 2.75 µg/mL at 5 minutes and 65 minutes afterthe event, respectively. The remainder of her postoperativecourse was uneventful, and she was discharged.

Author comment: "For the first case, partial intramuscularinjection of levobupivacaine leading to drug absorption couldbe the cause of the seizure". "In the second case, the mostlikely explanation [for the seizure] is secondary plasmaabsorption after an overdose of ropivacaine."Weiss E, et al. Convulsions in 2 patients after bilateral ultrasound-guidedtransversus abdominis plane blocks for cesarean analgesia. Regional Anesthesiaand Pain Medicine 39: 248-251, No. 3, May-Jun 2014. Available from: URL: http://doi.org/10.1097/AAP.0000000000000088 - France 803104289

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Reactions 7 Jun 2014 No. 15040114-9954/14/1504-0001/$14.95 Adis © 2014 Springer International Publishing AG. All rights reserved