LipidRescue™ Resuscitation

49 year old 114 kg. male for wrist surgery underwent supraclavicular block a full hour and a half prior to induction of general anesthesia. Block was performed by my partner utilizing ultrasound with Bupivicaine 0.5% with Epi 1:200k 30 ccs with negative aspiration prior to every 5 ccs injected. Patient tolerated this well. Approximately 40 minutes later it was noted that the Radial nerve distribution was not fully covered and a Radial nerve rescue block was performed utilizing ultrasound and using 10 ccs of 0.5% Ropivicaine. Almost an hour later the patient had a dense block and no symptoms of systemic toxicity. Vital signs were stable and normal. Patient preferred general anesthesia and the block was intended for post op pain relief. He was induced with Propofol and an LMA was placed. Shortly after induction, pt developed hypotension and tachycardia and was noted to be diaphoretic. The hypotension was very resistant to treatment and the pt was tenuously maintained with intermittent boluses of Phenylephrine and Ephedrine. Epinephrine 0.1 mg was given for continued hypotension with little effect. Calcium Chloride 200 mg boluses Xs 2 were given. The rhythm which had been sinus tachycardia changed to a severe bradycardia with ventricular escape beats and then to a rapid wide based tachyarrythmia. Intralipid 100 ccs was given as a bolus and followed with an Intralipid drip. The patient converted to a normal sinus rhythm within a couple of minutes. Blood pressure normalized within 10 minutes without the aid of further pressors. The patient was awakened at the completion of surgery without difficulty. He was watched for approximately 4 hours post op and was discharged home with no ill effects. He still had good pain relief the next morning and demonstrated no sequelae.

Mark,
thanks so much for sharing this amazing case. i find especially interesting your observation of the long delay to onset of symptoms. perhaps it was the general anesthetic which we find in rats will exacerbate the toxicity of bupivacaine. also of interest is the lack of response to pressors but rapid recovery of BP with lipid. glad it all worked out.
thanks
guy