Post Your Cases > Acute Lung Injury after succeful resuscitation of a cardiac arrest following caudal bupivacaine in a 3 yr old
Hi and thanks for posting. glad the baby is ok and that you were able to address successfully the cardiovascular collapse. The fever is concerning in that it suggests (esp in light of the A-a gradient) that aspiration might have occured during CPR (uncuffed tube). Epi is another possibility; see my recent paper in Anesthesiology, Krishnamoorthy et al. (anesthetized rats develop pulmonary edema after standard doses of epi). Based on your calculations (150mL/hr = .25mL/kg/min) it appears the baby weighed 10kg. Is that correct? Ths would suggest the total lipid dose was 17mL/kg which exceeds the standard dosing limit recommendations. Nontheless, I think the likelihood of lipid causeing the fever and pulmonary 'injury' is remote.
December 4, 2012 |
[Guy Weinberg]
[Guy Weinberg]
3year old female child presented with a swelling over the right calf. Preoperative MRI showed a deep seated, posterior compartmental, lipomatous lesion with an enhancing fibrous core noted in the right leg in relation with tibialis posterior muscle and splaying the tibial artery, of size 14.1* 6.1*5.2cm.
Surgical plan – excision with the patient in prone position
Pac – weight 11kg, ASA-1 otherwise unremarkable.
Anaesthetic plan – GETA + caudal.
Child was induced with sevo+N2O+ O2 , iv line secured, monitors attached. SpO2 100, ECG- HR 130/min (sinus tachycardia), NIBP 98/61mmHg (temperature, ET CO2 monitoring not available)
0.1mg Glycopyrrolate and 15mg of Suxamethonium was given, orotracheal intubation was done using no. 4 uncuffed ETT. Tube secured after confirming bilateral air entry. Atracurium 5mg iv given after patient started breathing spontaneously. Child maintained on GOS and IPPV and turned to right lateral for caudal.
Under strict aseptic precautions, the caudal epidural space was identified using a 22G scalp vein set by the landmark technique. Aspiration test was negative for both blood and CSF. 10ml of 0.25% Bupivacaine was injected in aliquots of 3ml each with repeated aspiration in between, which was again negative.
As the patient was returned to the supine position ECG showed two or three runs of VPC which subsequently progressed to a VT without pulse in a couple of seconds. 100% O2 was given.
CPR initiated, Inj. Adrenaline (1/10000) 0.3ml iv given.
Femoral pulse was palpable, however ECG showed a persisting VT, NIBP 90/68mmHg, SpO2 100
Intralipid 20% 15ml iv bolus was given. ECG dramatically reverted to sinus rhythm even as 4ml of this bolus was administered; however the full dose was given. Infusion of 20% intralipid started at 150ml/hour(0.25ml/kg/min) using a syringe pump. Another 5ml bolus was given 15minutes after the first bolus, though the child was haemodynamically stable (total volume given 170ml)
The monitor showed heart rate of 154/min, sinus rhythm, SpO2 100, NIBP 128/82mmHg, peripheral pulse was palpable, CRT was normal. The child was monitored closely. IPPV continued with 100% O2.
50 minutes later she started breathing spontaneously, and was extubated awake, after giving 1ml. of myopyrrolate as it was decided to postpone the surgical procedure. Vitals after extubation were HR 158/min, sinus rhythm NIBP 106/68mmHg, SpO2 100 on O2, RR- 24/min, moving her lower limbs well.
The child tended to be drowsy when undisturbed, therefore monitoring was continued.
1hour later, a mild respiratory distress in the form of intercostal indrawing, tachypnoea, tachycardia and desaturation (upto 82%) on removing O2 which promptly reverted to 100% on resuming O2. An ABG was done showed pH 7.23 , pCO2 37, pO2 56, Na+ 120, K+ 3.6, glucose 157mg%, HCO3 -15.3mmol/L, BE -12.1, SO2 82%, Hb 10.1g%, Hct 33%, lactate 13mg%.
2hrs post event, she was febrile, 100 oF, RR was 60/min, SpO2 95% on O2, HR 174/min, end expiratory wheeze was present and she continued to be drowsy, vomited once. IV fluids 200ml NS given, Inj. Lasix 5mg iv given. Nebulised with inj. Budesonide followed by Inj. Salbutamol nebulisation, the latter was stopped early as the tachycardia worsened, Paracetamol 120mg suppository as given.
4hrs postevent, peripheral venous blood gas analysis showed a pH of 7.31, pCO2 40, pO2 42, Na+135, K+ 3.9, ca++ 2.36meq/l , glucose 91mg%, lactate 18mg% HCO3- 20.1mmol/L ,BE- -6.2, SO2 72%, Hct32%, Hb 9.9g%.
Mild fever continued till 24 hrs post event, conservatively managed with suppository Paracetamol 6th hourly.
She was fully awake and alert 6hrs later, irritable the next day and playful 36 hrs later
Mild retching was present for12 hrs. iv RL 40ml/hr was given till 6hrs post event. oral fluids started by 6hrs, and normal appetite was restored by 24 hrs.
Tachypnoea and tachycardia gradually reduced. 12hrs later the HR-152/min sinus rhythm, RR- 40/min, SpO2 95 without O2. 330mg Solumedrol iv was given
48hrs later child active, playful, RR 32/min, chest clear, SpO2 98% on room air HR- 130/min.
Surgery was done 3 days later-it was uneventful.