LipidRescue™ Resuscitation

CNS TOXICITY SUBSEQUENT TO FEMORAL BLOCK WITH ROPIVACAINE:
RESCUE WITH INTRALIPID
A 58 yo male, 67’’, 89.6 kg was scheduled for a right knee hemiarthroplasty under general anesthesia. His past medical history was significant for chronic hepatitis C, GERD, hypothyroidism, hypertension, CAD, DJD, hyperlipidemia, osteoarthritis, and mood disorder. His laboratory work up was normal except for a platelet count of 138. His examination was within normal limits with BP 162/77 mmHg, HR 62 bpm and SpO2 98% on room air. Benefits and risks of a single shot femoral block were explained and consent obtained. Standard ASA monitors were placed and the patient was premedicated with midazolam 1 mg and fentanyl 50 mcg iv. Under sterile precautions, a 22 G 2’ stimuplex needle was passed in the right femoral region in plane under ultrasound guidance and the vasculature and nerve were identified. Nerve stimulation was positive ≥ 0.65mA. RAJ was positive after 1 cc. Incremental injection of a total of 40 cc of ropivacaine 0.5% with 1:400,000 epinephrine was given perineurally after checking for negative aspiration every 5 cc. The needle tip was localized, and spread of medication was observed for all but the last 10 cc of injection. The patient denied any signs of systemic toxicity and vitals remained stable at first. Forty-five seconds later the patient developed a stiff face, started staring, and became agitated with involuntary movements of both arms and legs. HR rose to 122 bpm, BP 180/90 mmHg, SpO2 98%. Midazolam 1.5 mg iv was immediately given and 20% Intralipid (total dose 80cc) started. The patient regained consciousness and was oriented x 3 within 2 minutes, moving all limbs without deficit. He complained about a bad dream, but had no recall and was otherwise stable. He was later taken to the OR and underwent an uneventful surgery under GETA. Postoperatively, he required iv opioids for pain relief due to an only partial right femoral nerve block.