Post Your Cases > Intralipid treatment of bupivicaine toxicity in Sciatic Block

A 70 year-old female with history a CABG went for a total knee replacement under spinal anesthesia with a continuous femoral nerve block for post-op analgesia (Ropivicaine 0.2% at 8mL/hr). Patient continued to have pain in a sciatic distribution after several doses of narcotic. A sciatic block was performed with Bupivicaine 0.5% 30mL with negative aspirations every 5 mL. 1-2 minutes later the patient began to have tonic-clonic seizures. The patient was assisted with ventilation and given midazolam 2mg. She then progressed to V-tach with a pulse. A single shock of 50Joules was administered with conversion to sinus rhythm. 60mL of 20% Intralipid was administered and an infusion was begun. The patient remained hemodynamically stable.
The next day she underwent cardiac catheterization and electrophysiology studies. She had induced V-tach during the EPS and an AICD was implanted that afternoon.
March 2, 2007 | Unregistered CommenterEric Diana, MD
There is unquestionably a subset of patients with a lower than normal threshold for LA-induced cardiac toxicity. Seems that patients wiht pre-existing conduction defects, ischemic heart disease or low cardiac output are over represented among the reports of LA-tox I'm reading. Interestingly, or paradoxically, I should say, these are exactly the patients we usually prefer RA for, aren't they? We'll now add EP abnormalities to that list. Thanks, Eric. Could you get any sense as to whether the ECG improved after the lipid infusion? Any changes in BP with lipid? Thanks again for posting. Stay in touch. Guy
March 6, 2007 | Registered Commenter[Guy Weinberg]
Outstanding work, In addition to probable underlying cardiac electophysiologic issues, let's not forget the existing infusion of ropivicaine (any PCA cappability with that?). Possibility of bupivicaine 0.5% X 30 mls in a 70 year old patient with comorbidities being pushed into relative toxic blood levels.
November 30, 2007 | Unregistered CommenterThomas Jarecky M.D.