Post Your Cases > LA allergy and ?LA toxicity

We had a recent case of a possible anaphylaxis to Levobupivacaine and ? inadvertent LA toxicity. 50yr old gentleman with lymphoproliferative disorder presenting for lymph node bx at left neck region under GA. Apparently healthy otherwise. No history of allergies whatsoever and had dental procedures under LA (?type) before.

GA+LMA following Fentanyl + Propofol. Anaesthesia maintained with Sevo/O2/Air. Patient was stable throughout the operation. At the end, just before skin closure (after 40min), surgeon infiltrated 5mls 0.5% Levobup to surgical wound. Few minutes after, BP noted to be in low 50s (SBP) that did not respond to phenylephrine and ephedrine boluses. ECG showed sinus bradycardia. Patient was ventilated with 100%O2. Repeated boluses of Adrenalin 1:10000 was administered for unsustained improvement in BP. LMA changed to ETT. Meanwhile, ECG rhythym degenerated again to bradycardia with ST elevation followed shortly by high grade heart block patterns. Patient was struggling somewhat and we had to paralysed him with Cis-Atracurium. Skin changes became evident with generalised orange peel appearance over the trunk, arms and face and felt like the bark of tree trunk. Presence of bronchospasm was detected on auscultation and airway pressures were elevated. We treated him as for anaphylaxis. He experienced 2 episodes of VF requiring chest compression and defibrillation. We had intralipid ready but the cardiac rhythm remained stable after the 2nd defib. CVL was quickly inserted and IV infusion of adrenalin commenced to stabilize the BP. The patient remained stable after subsequently. All in all, we took about 30mins to stabilise his haemodynamics and ventilation.

He was transferred to ICU. Echo showed some hypokinetic segment mainly affecting the RV. Troponin I was elevated. He remained stable with no further arrhythmias. Inotrope could be weaned off and he was extubated the next day. No neurological deficit was detected. Repeat echo showed improvement in RV function.

Drug allergy to amide LA is rare; only 2 case reports involving levobupivacaine have been reported to my knowledge (Anaesthesia journal). Serum tryptase results will only be known by end of the month. As there maybe an element of LA toxicity with inadvertent intravascular administration, we would be interested in serum level of levobupivacaine but we don't know if our local lab will do serum levobupivacaine (taken about 1hr after).

Any comments anyone? Do you think we should have given intralipid early?
August 12, 2013 | Unregistered CommenterJ Kua
this is a very intriguing case and I thank you for posting. The initial presentation is very consistent with LA systemic toxicity. I consider the progressive bradycardia and pressor-resistant hypotension almost pathognomonic. The small dose is not inconsistent given that there is a subpopulation of patients with extremely low threshold for LA toxicity. The appearance of a systemic anaphylactoid appearance does give one pause and I wonder if this might be a response to the cisatracurium injection given the chronology. I think it would be reasonable to use lipid early in this patient (no downside in this setting) and treated for anaphylaxis as a separate issue.
September 27, 2013 | Registered Commenter[Guy Weinberg]
To close the case, serum tryptase was elevated. The result of skin testing including serum IgE challenge tests reveal the patient is allergic to chorhexidine that was used to disinfect the surgical wound before closure.
December 24, 2013 | Unregistered CommenterJ Kua
Thanks!
December 27, 2013 | Registered Commenter[Guy Weinberg]