Post Your Cases > Rescue of Surgeon Induced Bupivacaine Toxicity in a Patient Under General Anaesthesia
A 31 year old, healthy, 75kg, ASA I patient was approximately one hour into an otherwise uneventful myomectomy under GETA when the surgeon, without warning, injected 50cc of 0.25% bupivacaine with epinephrine directly into the uterus. Moments later the patient developed a bigeminal rhythm and the non-invasive blood pressure (NIBP) cuff, although it did cycle, did not capture. We immediately sent for 20% Intralipid, which was started within 8 minutes of the onset of bigeminal episode. Subsequently, the patient went back into sinus rhythm, but developed ominous T-wave inversions and ST segment depression in leads II and V5. NIBP was 70/30, rate of 60-70. While we were getting the lipid started we supported her circulation with a 500cc bolus of 6%Hetastarch and phenylephrine boluses. She was also placed in a head-down position, administered 100% O2 and the level of volatile agent decreased. Midazolam 5mg IV was also administered for any occult seizure activity,since the patient was relaxed with rocuronium. We administered the Intralipid per protocol and within 15-20 noted reversal of the ECG changes. A second round of Intralipid was administered 20 minutes after the first dose. Within 40 minutes the patient's hemodynamics and EKG returned to baseline. She was extubated at the end of the case and brought to the PACU where a 12-lead EKG was obtained, which was essentially normal. Cardiac enzymes were also obtained at that time. The patient was admitted to the ICU and evaluated by Cardiology prior to discharge. A TTE was performed the following day, which revealed normal function. She ruled out for a MI. The patient was discharged home in good and stable condition. The surgeon was educated on the intra-op use of local anaesthestics and preferably, in the future, to discuss such measures with the anaesthesia team prior to administration.
Moments later the patient developed a bigeminal rhythm and the non-invasive blood pressure (NIBP) cuff, although it did cycle, did not capture. We immediately sent for 20% Intralipid, which was started within 8 minutes of the onset of bigeminal episode. Subsequently, the patient went back into sinus rhythm, but developed ominous T-wave inversions and ST segment depression in leads II and V5. NIBP was 70/30, rate of 60-70. While we were getting the lipid started we supported her circulation with a 500cc bolus of 6%Hetastarch and phenylephrine boluses. She was also placed in a head-down position, administered 100% O2 and the level of volatile agent decreased. Midazolam 5mg IV was also administered for any occult
seizure activity,since the patient was relaxed with rocuronium. We administered the Intralipid per protocol and within 15-20 noted reversal of the ECG changes. A second round of Intralipid was administered 20 minutes after the first dose. Within 40 minutes the patient's hemodynamics and EKG returned to baseline.
She was extubated at the end of the case and brought to the PACU where a 12-lead EKG was obtained, which was essentially normal. Cardiac enzymes were also obtained at that time. The patient was admitted to the ICU and evaluated by Cardiology prior to discharge. A TTE was performed the following day, which revealed normal function. She ruled out for a MI. The patient was discharged home in good and stable condition. The surgeon was educated on the intra-op use of local anaesthestics and preferably, in the future, to discuss such measures with the anaesthesia team prior to administration.