LipidRescue™ Resuscitation

Seventeen year old ASA I male (6 ft, 197#) presented for ACL reconstruction under GA with a preoperatively administered post-op pain block, utilizing a combined Fem-Sciatic technique.
The patient received 2mg midazalam and 50mcg fentanyl via 20ga peripheral IV, prior to the femoral portion of the technique. Standard monitoring was in place as well as supp O2 a 2 lpm via nasal canula. The nerve block was placed with a 2 inch stimuplex needle with stimulation of the quad to <0.1 mA. 20 ML of 0.5% Bupiviaciane with 1:200k epi administered in 5ml increments with a negative aspiration of blood to a total dose of 20mls. Pt. responded appropriately with stable vital signs. Pt received an additional 50mcg fentanyl while positioning of leg for the sciatic portion of technique. The sciatic nerve was stimulated to <0.2 mA via 4 inch Stimuplex needle, negative aspiration of blood, divided doses of the same bupivicaine mixture were administered in 5ml doses until 15mls were administered without symptoms of toxicity. During the next 5ml dose the pt stated "I can't breath," the technique was aborted at that time with a total dose of 18mls being administered.
Additional staff support was obtained, the pt began exhibiting sz activity. An additional 2mg of midazalam was administered, sz activity did not subside, and the symptoms appeared to be worsening. It was then decided to administer the Intralipid infusion at that point. The IntraLipid infusion was infused by gravity through a 15gtt/ml infusion set with the roller clamp wide open (20 ga IV cath). After approximately 75-100 mls had infused, the sz activity subsided and the patient began responding appropriately to verbal stimulus and after approximately 200mls was administered, the Pt appeared sedate but alert & oriented to name, place, time and person. The infusion was allowed to completely infuse (total dose 500ml). The patient was monitored for approximately 3 hrs prior to discharge. The surgery was rescheduled for a later date.

Dear Mr. Smith, Good work taking care of this frightening complication! I was wondering if the patient was offered another block when he returned for his surgery later on? Did he accept? It seems especially tricky since the first block seemed so uneventful (negative aspiration) at first. Do you think it was due to accidental IV injection or do you think the total dose was too high for the patient to tolerate? Please reply. Thank you!!!

Dr Sowinski, So sorry for the slow response. Upon return to the facility the Pt & guardian both agreed with proceeding with a Fem/Sciatic block a week later. The blocks were performed without incident. My feeling was that this Pt experienced an accidental intravascular uptake. Thank you for your response.