Post Your Cases > Lipid rescue of LAST following Peribulbar block

We had a case of local anaesthetic toxicity following a peribulbar block for cataract surgery and lens implant . The case is outlined below.

A 55 year-old, 68 kg male was scheduled for cataract surgery and lens implant for his right eye. He was a hypertensive on oral Amlodipine 5 mg OD, no history of any other preexisting medical illness, drug allergies or previous surgeries. His preoperative investigations and electrocardiogram (ECG) was normal.

He was allowed a light breakfast at 6 AM, antihypertensive medication was continued on the morning of surgery. His systemic examination was unremarkable, the blood pressure which was found to be 136/82 mmHg on the morning of surgery. After the eyelids were prepared with a betadine pad and ensuring that the eye was kept in the primary gaze position, a 24 G 25 mm needle was introduced through the skin of the lower lid sulcus at the inferolateral angle of the orbit. The needle was inserted along the orbital wall to a depth of 2 cm. After negative aspiration, a mixture bupivacaine 25 mg, lidocaine 100 mg and hyaluronidase 500 IU mixture (10 ml volume) was injected by an ophthalmology resident. No second injection (supero-medial) was done. The patient had a grand-mal seizure immediately on removal of the needle.

The anaesthesiologists help from the adjacent theatre saw sought, Inj midazolam 1.5 mg intravenous (i.v) was administered after securing an 18G i.v line on the dorsum of the hand. Simultaneously the patient was mask ventilated with 100% oxygen. The ECG showed a heart rate of 130 beats / min with multiple supraventricular ectopic beats, blood pressure of 180/104 mm Hg and oxygen saturation of 98%.The patient had no further seizures, but he was disoriented and responsive to only painful stimulus. Pupillary reaction could not be assessed due to the dilatation. A random blood sugar showed 136 mg/dl. He was breathing regularly with good tidal volume.

A probable diagnosis of LAST was done in view of seizures and cardiovascular instability. To prevent further deterioration of the patient the decision to initiate lipid emulsion therapy was taken. 100 ml bolus of lipid emulsion (Intralipid™ 20%) over one minute followed by 600ml over 30 minutes was infused. The patient regained full consciousness and was oriented 5 minutes after the initial bolus of lipid. ECG reverted to normal sinus rhythm 10 minutes after initiating the infusion. The surgery was deferred and the patient was shifted to the intensive care unit, the patient was discharged after monitoring the for the next eight hours as 12 lead ECG showed no fresh changes and other investigations were normal.

Although we could successfully manage LAST, are we justified in using lipid rescue in our case?
January 16, 2015 | Unregistered CommenterDr Vinayak Pujari (MD)
can ACLS drugs be given trough the same IV as the lipids?
January 17, 2015 | Unregistered Commenterr.mahana