LipidRescue™ Resuscitation

42 year old woman for elective TVT insetion. ASA1. Wt 59kg. GA with TCI propofol and remifentanil. Uneventful until patient developed bigeminy intraop. BP rose from 100/50 to 134/70 and HR 50/min. Surgeon confessed to doing an intravascular injection of an unknown volume (probably between 1 and 5mls) of 0.25% levobupivacaine with 1 in 100,000 Adrenaline just at the end of the local infiltration along the track of the TVT tape. Total volume used 75-80ml of 0.25%levo with adrenaline. Patient not paralysed, no abnormal movements seen. BP settled to previous levels and bigeminy spontaneously reverted without treatment within 90 seconds. Rest of the operation uneventful. LMA removed when patient opened eyes at end. However after 15 minutes in recovery patient had not woken up any more. Very drowsy, refusing to open eyes but would move to command, making exaggerated head nodding and shaking to questions but not speaking at all. After another 5 minutes developed twitching of upper body and arms. On direct questioning (as patient only able to nod yes or no) patient felt light headed, drowsy, weird, odd, confused and not orientated in place. GCS 11-13. Observed for 20 mins but no improvement so gave bolus dose of 100ml 20% intralipid and commenced infusion at 15ml/kg/hr. Total dose given 900ml. Within 5 minutes of the bolus patient sitting up chatting, smiling, orientated and feeling totally normal. Only had very vague recall of events in recovery room. Post op 12 lead ECG normal and amylase at 24 and 48 hours within normal range. Patient went home following day (20 hours post event). I suspect CNS toxicity due to gradual rise in plasma levels from the infiltration on top of an already raised baseline level due to the intravascualr injection. also total dose for her weight should be 147mg of levobupicvacaine (taking 2.5mg/kg as safe)and she received between 187.5mg and 200mg.