51 year old Male ASA2 No medical history except well controlled Type 2 Diabetes, had Uncemented knee replacement under Spinal anaesthetics and 5mg Midazolam for sedation- uneventful all throughout 65 minutes intraoperative except for vasovagal at first attempt at spinal insertion.
While getting L-Bupivacaine infiltration(54mL of 0.125% injected in at the time)- Developed sinus bradycardia followed by sinus arrest followed by idioventricular rhythm, Unresponsive, pale, Systolic BP not recordable, airway maintained, breathing spontaneously, SpO2 100% on face mask 3L/min.
Stopped further infiltration, given 100% Oxygen, Atropine 600mg, Ephedrine 15 mg and 100mL Intralipid (followed by 400mL over 20 minutes later) Responded with HR 60/min, BP 120/80, still pale but fully conscious, Still C/O tingling tongue and face, dry mouth, feeling funny, 12 lead ECG-no abnormality, Electrolytes normal, blood sent for Bupivacaine levels, Tryptase and IgE
4 hours later, in PACU,while having 2nd venepuncture for blood sampling(as above) developed Bradycardia(HR in 20’s, systolic BP in 50s), responded with Ephedrine 12 mg, has had 12 mg Morphine for pain as spinal had worn off.
On further questioning, patient revealed history of fainting episodes in the past with needles. Any cardiac pathology was ruled out on cardiology review. L-Bupivacaine level at 35min post event were 1.36ug/mL and 0.76ug/mL at 4 hours later. IgE to Bupivacaine, Mast cell Tryptase, and Total IgE were well with unremarkable.
I believe this was caused by Toxic levels of Bupivacaine, needle induced vasovagal episodes were only distracting co-incidences. Intralipid bolus was given with 2 minutes of ECG changes along with other supportive treatment- which could have helped to prevent further deterioration needing any cardiopulmonary support e.g. intubation, ventilation, CPR
While getting L-Bupivacaine infiltration(54mL of 0.125% injected in at the time)- Developed sinus bradycardia followed by sinus arrest followed by idioventricular rhythm, Unresponsive, pale, Systolic BP not recordable, airway maintained, breathing spontaneously, SpO2 100% on face mask 3L/min.
Stopped further infiltration, given 100% Oxygen, Atropine 600mg, Ephedrine 15 mg and 100mL Intralipid (followed by 400mL over 20 minutes later)
Responded with HR 60/min, BP 120/80, still pale but fully conscious, Still C/O tingling tongue and face, dry mouth, feeling funny, 12 lead ECG-no abnormality, Electrolytes normal, blood sent for Bupivacaine levels, Tryptase and IgE
4 hours later, in PACU,while having 2nd venepuncture for blood sampling(as above) developed Bradycardia(HR in 20’s, systolic BP in 50s), responded with Ephedrine 12 mg, has had 12 mg Morphine for pain as spinal had worn off.
On further questioning, patient revealed history of fainting episodes in the past with needles. Any cardiac pathology was ruled out on cardiology review.
L-Bupivacaine level at 35min post event were 1.36ug/mL and 0.76ug/mL at 4 hours later.
IgE to Bupivacaine, Mast cell Tryptase, and Total IgE were well with unremarkable.
I believe this was caused by Toxic levels of Bupivacaine, needle induced vasovagal episodes were only distracting co-incidences.
Intralipid bolus was given with 2 minutes of ECG changes along with other supportive treatment- which could have helped to prevent further deterioration needing any cardiopulmonary support e.g. intubation, ventilation, CPR