Post Your Cases > Successful use of Intralipid for Lidocaine induced CNS toxicity following ultrasound guided axillary brachial plexus block
The usefulness of Intralipid is well established for management of cardiac toxicity following local anaesthetic injection. We would like to highlight a case where we believe it was extremely useful in management of CNS toxicity following lidocaine possibly due to inadvertent intravascular injection
21/M. Scheduled for exploration and removal of metal foreign body left forearm with repair of superficial radial nerve. No past medical history. Allergy to Penicillin. No routine medications
After establishing IV access and routine monitoring (Pulseoximetry, ECG, NIBP) axillary block was done under ultrasound guidance using 22G 50mm Pajunk peripheral nerve stimulator needle. 2%lidocaine with 1:200,000 adrenaline with frequent aspiration and ultrasound confirmation of extravascular injection, was used. Towards the end of the block patient complained of 'shaky legs'. The injection was immediately stopped. 18mls was given in total upto this point. Oxygen administered through facemask. Simultaneously he complained of 'hearing a siren', became disoriented but not agitated and the mental status appeared to be waning. He had jerking movement of both upper and lower extremities(seizures). He had not lost consciousness. 20%Intralipid 125mls bolus was given with immediate recovery of neurologic function though the seizures persisted for a further two minutes. The total episode lasted 4minutes during which he was tachycardic (120s)and hypertensive (systolic 160s) . A further bolus of 20%Intralipid 125mls was given and infusion started. There was complete resolution of symptoms. He made a remarkable recovery very quickly. In view of the fact that his arm was anaesthetised, he had stable hemodynamics and neurology, a decision was taken to proceed with surgery. As the block was stopped before the radial nerve was blocked a radial nerve top-up was done in the forearm (4mls 1%Lidocaine with adrenaline 1:200,000). This was well tolerated by the patient. Surgery was uneventful. Patient was ready for discharge to home but as a precautionary measure he was kept in overnight.
Although it could be argued that the patient could have made a complete recovery even without the administration of intralipid, we believe it did play a vital role in hastening neurologic recovery.
21/M. Scheduled for exploration and removal of metal foreign body left forearm with repair of superficial radial nerve. No past medical history. Allergy to Penicillin. No routine medications
After establishing IV access and routine monitoring (Pulseoximetry, ECG, NIBP) axillary block was done under ultrasound guidance using 22G 50mm Pajunk peripheral nerve stimulator needle. 2%lidocaine with 1:200,000 adrenaline with frequent aspiration and ultrasound confirmation of extravascular injection, was used. Towards the end of the block patient complained of 'shaky legs'. The injection was immediately stopped. 18mls was given in total upto this point. Oxygen administered through facemask. Simultaneously he complained of 'hearing a siren', became disoriented but not agitated and the mental status appeared to be waning. He had jerking movement of both upper and lower extremities(seizures). He had not lost consciousness. 20%Intralipid 125mls bolus was given with immediate recovery of neurologic function though the seizures persisted for a further two minutes. The total episode lasted 4minutes during which he was tachycardic (120s)and hypertensive (systolic 160s) . A further bolus of 20%Intralipid 125mls was given and infusion started. There was complete resolution of symptoms. He made a remarkable recovery very quickly. In view of the fact that his arm was anaesthetised, he had stable hemodynamics and neurology, a decision was taken to proceed with surgery. As the block was stopped before the radial nerve was blocked a radial nerve top-up was done in the forearm (4mls 1%Lidocaine with adrenaline 1:200,000). This was well tolerated by the patient. Surgery was uneventful. Patient was ready for discharge to home but as a precautionary measure he was kept in overnight.
Although it could be argued that the patient could have made a complete recovery even without the administration of intralipid, we believe it did play a vital role in hastening neurologic recovery.