Reactions 1504, p24 - 7 Jun 2014

SRopivacaine

Local anaesthetic systemic toxicity: case reportA 67-year-old woman developed local anaesthetic systemic

toxicity (LAST) following local infiltration analgesia (LIA) withropivacaine.

The woman presented for polyethylene tibial insertexchange of her previous total knee arthroplasty and received100mL of 0.2% ropivacaine [route not stated] with epinephrinefor posteromedial and posterolateral infiltration of the dorsalcapsule, 50mL of 0.2%ropivacaine with epinephrine forinfiltration of the anterior capsule and 50mL of 0.2%ropivacaine without epinephrine for infiltration of the skin andsubcutaneous tissues of the surgical incision with the totaldose of ropivacaine being 400mg. Seventy-five minutes postLIA, she developed atrial fibrillation with a ventricle responseup to 150 beats per minute (bpm) and experiencedretrosternal pain along with agitation.

The woman was treated with nitroglycerin and metoprolol.Five minutes later, she lost consciousness and developed aclonic seizure with convulsions of her arms, legs and facialmuscles, and was diagnosed with LAST. She received oxygen,midazolam boluses, lipid emulsion infusion and herconvulsions improved rapidly with spontaneous breathing.After around five minutes she regained consciousness, butduring the next 15 minutes she experienced 2 additionalmilder episodes of generalised convulsions and decreasedconsciousness lasting for approximately 20 to 30 secondseach. Her heart rate came back to 100–120 bpm, she feltdrowsy and did not experience retrosternal pain. During thehours after her transfer to the postanaesthesia care unit, sheexperienced several short episodes of focal convulsionsdecreasing in intensity over time, lasting for seconds andlimited to her arm or a leg. However, she remained consciousduring this period. Her sinus rhythm was restoredspontaneously and her last observation which was 5.5 hourspost LIA detected a minor convulsion. No further eventsoccurred thereafter and she was transferred to a ward in goodcondition without sequelae.

Author comment: "We present a case of late systemictoxicity occurring 80 minutes after local infiltration of theknee with 400 mg ropivacaine 0.2%". "Our case is unusual inthat cardiac symptoms preceded central nervous systemsymptoms, and toxic symptoms persisted for 5 hours.""However, we feel that the clinical picture and resolution ofsymptoms in our patient are evident and sustain thediagnosis of [local anaesthetic systemic toxicity]."Fenten MGE, et al. Systemic local anesthetic toxicity after local infiltrationanalgesia following a polyethylene tibial insert exchange: A case report. RegionalAnesthesia and Pain Medicine 39: 264-265, No. 3, May-Jun 2014. Available from:URL: http://doi.org/10.1097/AAP.0000000000000077 - Netherlands 803104389

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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