Post Your Cases > Delayed LA toxicity?

70 y.o fit male 9 Hypertension on meds, controlled) for hand fasciotomy (thumb and little finger) 96,3 kg. Brachial plexus supraclavicular block with Lidocaine 2% 20 mls and Levobupivacaine 0.375% 15 mls. plus periferal nerve blocks on forearm - radial, median and ulnar nerves - 3 mls of 2% Lidocaine on each nerve. Uneventful.
Waited for surgery around 1 h.. Surgery under tourniqet.
Had thumb done and started to complain on some pain when surgeon moved to little finger. Additional 1% Lidocaine with Adrenaline 5 mls. - successful top-up by surgeon.
Tourniqet time totally 55 mins. After release of the tourniqet became bradycardic 60 to 35 bpm, hypotensive 150/90 to 75/30 mm. Conscious, only comlain is headache.
Ephedrine 6 mg boluses and Glycopyrrolate had no effect at all.
Intralipid 100 ml bolus and another 100 ml a little slower restored all vital signes. All action - about 10 mins. Followed by infusion of another 100 mls of Intralipid.
Uneventful recovery. , went home 3 h after.
October 17, 2014 | Unregistered CommenterAndrei Rebrov
Very nice job, Andrei. Your case points out a few things. First, there are patients with a lower-than-normal threshold for LAST...particularly the elderly (especially with low muscle mass) and pre-existing cardiac condition (especially ischemic heart disease...makes me wonder about your patient). And of course, toxicity can be delayed and appear only after an event that further lowers the threshold e.g., a drop in pH as can occur as the tourniquet goes down. Finally, it's very possible to have only cardiac signs without CNS toxicity, even though the text books would have you believe otherwise. Thanks for posting. Guy
December 22, 2014 | Registered Commenter[Guy Weinberg]