Successful Resuscitation: After interview, standard monitors placed and oxygen supplement flowing, time out done IAW standard protocol; pt received 2mg IV Midazolam and 50mcg IV fentanyl. Femoral n block w 30cc 0.25% bupiv w 1:400k epi w/o complications. Pt received additional 50mcg fentanyl before positioning for sciatic block (RT lateral decubitus position). After achieving foot twitch at 0.4mA and after negative aspiration on syringe by assistant, injection in pts left gluteal area w 30cc 0.25% bupiv w Epi (1:400K) was completed, with several aspriations by assistant (all negative for heme) just after needle withdrawl pt began shaking upper extremities then lower extremities. Since pt had been sedated prior to injection, he did not indicate early nor subjective ssx of local anesthetic toxicity. Pt was not hemodynamically unstable and was immediately placed supine, supportive oxygen via Ambu bag assisting pts own respiratory efforts was initiated. Pt was hemodynamically stable, so ~40mg Propofol was given immediately. Intra lipid 20% bolus 150+mL (pt weight ~105kg) over ~1-2 minutes was given immediately follwoing propofol; initiated within 30-seconds of onset of myoclonic activity. Pt EKG showed increase of HR from baseline 80's to 90's and BP increased from baseline to ~170's/140's. Pts shaking subsided within the first 30sec-to-1 minute of the intralipid bolus, and his breath efforts remained strong (with jaw support) so no intubation was done. Pt was continually monitored and intralipid infusion was decreased to 27mL/minute after pt regained consciousness and purposeful movement. Within 3 minutes of awakening, pt was able to move all 4 extremities (except with femoral n blocked, as expected), follow commands, told us correct date, place, and his own name. pt appeared to recover completely, though stated he felt "relaxed" likely from the remaining sedative medications in his body. ICU was consulted, 12-lead EKG was done, pt was taken in monitored status to ICU and report given to ICU attending (Dr. **********). As pt was hemodynamically stable, Intra lipid was stopped after ~30minutes; having received approximately 400mL total. Pt scheduled to return to surgery for ACL tomorrow, barring unforseen events this evening, so should be NPO after midnight. Care transferred to ICU w anesthesia available always at ###-####. Notes:Pts total dose of bupivacaine was 150mg, with 150mcg total epinephrine- 75mg Bupivacaine and 5mcg epi given during femoral block (which was appaprently w/o issue) and the reminder administered w sciatic block; and total event from onset of myoclonic activity to resolution was ~2 minutes. Pt also received 2mg midazolam, 100mcg fentanyl, 40mg propofol, and a partial dose of cefazolin (approximately 500mg), in addition to lactated ringers iv fluids.
After interview, standard monitors placed and oxygen supplement flowing, time out done IAW standard protocol; pt received 2mg IV Midazolam and 50mcg IV fentanyl. Femoral n block w 30cc 0.25% bupiv w 1:400k epi w/o complications. Pt received additional 50mcg fentanyl before positioning for sciatic block (RT lateral decubitus position). After achieving foot twitch at 0.4mA and after negative aspiration on syringe by assistant, injection in pts left gluteal area w 30cc 0.25% bupiv w Epi (1:400K) was completed, with several aspriations by assistant (all negative for heme) just after needle withdrawl pt began shaking upper extremities then lower extremities. Since pt had been sedated prior to injection, he did not indicate early nor subjective ssx of local anesthetic toxicity. Pt was not hemodynamically unstable and was immediately placed supine, supportive oxygen via Ambu bag assisting pts own respiratory efforts was initiated. Pt was hemodynamically stable, so ~40mg Propofol was given immediately. Intra lipid 20% bolus 150+mL (pt weight ~105kg) over ~1-2 minutes was given immediately follwoing propofol; initiated within 30-seconds of onset of myoclonic activity. Pt EKG showed increase of HR from baseline 80's to 90's and BP increased from baseline to ~170's/140's. Pts shaking subsided within the first 30sec-to-1 minute of the intralipid bolus, and his breath efforts remained strong (with jaw support) so no intubation was done. Pt was continually monitored and intralipid infusion was decreased to 27mL/minute after pt regained consciousness and purposeful movement. Within 3 minutes of awakening, pt was able to move all 4 extremities (except with femoral n blocked, as expected), follow commands, told us correct date, place, and his own name. pt appeared to recover completely, though stated he felt "relaxed" likely from the remaining sedative medications in his body. ICU was consulted, 12-lead EKG was done, pt was taken in monitored status to ICU and report given to ICU attending (Dr. **********). As pt was hemodynamically stable, Intra lipid was stopped after ~30minutes; having received approximately 400mL total. Pt scheduled to return to surgery for ACL tomorrow, barring unforseen events this evening, so should be NPO after midnight. Care transferred to ICU w anesthesia available always at ###-####. Notes:Pts total dose of bupivacaine was 150mg, with 150mcg total epinephrine- 75mg Bupivacaine and 5mcg epi given during femoral block (which was appaprently w/o issue) and the reminder administered w sciatic block; and total event from onset of myoclonic activity to resolution was ~2 minutes. Pt also received 2mg midazolam, 100mcg fentanyl, 40mg propofol, and a partial dose of cefazolin (approximately 500mg), in addition to lactated ringers iv fluids.