Post Your Cases > Local anaesthetic toxicity after peribulbar block

A 66 year old lady was booked for an elective cataract extraction. She had a background of previous hemicolectomy for bowel cancer, GORD, bilateral vitrectomy over a year ago under peribulbar block. She had 500 micrograms of alfentanil then a peribulbar block with a 25g 25 mm sharp needle. Slow incremental injection of a total of 8 ml of 1% ropivocaine with 15units/ml of hyalase was injected. Of note, no blood was aspirated at any stage, not even a small flash into the needle, and I aspirated frequently during the injection. No subjunctival haemorrhage occurred. Also, there was not the usual degree of proptosis that I would have expected with a peribulbar block which was of concern. 1 minute after the injection was completed the patients' heart rate began to rise from 60bpm to 94bpm. No ectopics. Also the blood pressure rose from 160/85mmHg to 225/115mmHg. Simultaneously she became unresponsive and started twitching. An arrest was called and she quickly received midazolam 2mg IV then 20mg propofol. By now she was having a grand mal seizure. The seizure abruptly terminated with the above. Airway support and ventilation was assisted. Intralipid 20% 60ml (1ml/kg) was given as soon as the propofol was given followed by an infusion of just under 0.25ml/kg/min. She awoke 10min later and remained haemodynamically stable. The Intralipid infusion was ceased about 10 min later as haemodynamics were steady and the infusion is painful when given via peripheral cannula. ECG and overnight monitoring was unremarkable.
This was clearly an inadvertent intravascular injection of ropivocaine. She had a partial eye block so only a portion of the injected dose went intravascular.
June 17, 2015 | Unregistered CommenterJohn Petrovski