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Uneventful Supraclavicular nerve block for awake elbow surgery - US control with good view of LA spread and regular aspiration througout injection. 89 kg man - 15 mls of 2% lignocaine with adrenaline and 15 mls of 1% prilocaine - so below toxic dose limits. Excellent onset of block. bradycardia down to 42 after 5 mins, patient felt fime. Treated with glycopyrrolate and ephedrine with increase to 48 bpm. Then sudden drop to < 10 bpm and broadening of complexes with reduced LOC. 100% oxygen given by circuit - patient still breathing spontaneously. 1mg of Adrenaline given with immediate response. Intralipd -2 100 ml boluses followed by the remaining 300 mls at 1L/h. Patient recovered quickly - C/O of lower back pain but nil else.Total intralipd dose given was 500 mls. Totally stable after 15 - 20 minutes. Perfect block. Surgery proceeded after 45 minutes and then patient observed overnight on HDU and discharged the following day Amylase and Lipase normal at 24 and 48 hours.Uneventful recovery. Presumed rapid absorption and bolus effect with brief high plasma levels - absolutely convinced no direct IV injection.
June 27, 2013 | Unregistered CommenterMelanie Dakin
Hi Melanie,
thanks for posting this very interesting case. There is just no predicting how the individual will present with LAST. Here, you saw a 'double dip', where the first appeared to respond to simple measures but the second was much more severe. This is very reminiscent of one of our animal models where BP suddenly drops after the bupivacaine bolus, recovers for a short while, then a minute later drops again but more severely and, without lipid, takes a long time to recover. You can see plots of these experiments in the upcoming resuscitation-themed issue of Anesthesiology. Your patient, thankfully, received the lipid. Good job!! and thanks again for the post
September 27, 2013 | Registered Commenter[Guy Weinberg]