Post Your Cases > LAST after Distal Sciatic and Distal Femoral Nerve Block

A 47 year-old woman (65kg) with IDDM and HLD was seen in the PACU s/p external fixation of a tibia/fibula fracture. She initially received a distal sciatic nerve block with mepivacaine 1.5% 10mL and ropivacaine 0.5% 10mL. Because she described significant pain at the medial ankle, she then received a distal femoral nerve block with mepivacaine 1.5% 10mL and ropivacaine 0.5% 10mL. Immediatley after both blocks were completed, the patient's nurse provided dilaudid 1mg IVP for pain control.

Five minutes after the dilaudid was provided, the nurse called us to the patient's bedside because she was somnolent; on exam she did not arouse to command but was reactive to painful stimuli. She was maintaining oxygen saturation and was hemodynamically stable. Since she had just received dilaudid 1mg IVP and had received dilaudid 2mg IVP at the end of the orthopedic case, it was believed she had received sufficient narcotics to reduce responsiveness but that was not in danger of compromised airway.

A total of 20 minutes after both nerve blocks had been placed, we were called to the patient's bedside, where she was seizing. She was immediately given midazolam 2mg IVP. She stopped seizing. She was bag-mask ventilated to maintain saturation although it was noted she was breathing spontaneously. She was tachycardic and hypertensive. Lipid emulsion 20% 100cc IVP was given and then infusion started. She was intubated without any difficulty because she continued to have altered mental status and could not maintain oxygenation without bag-masking.

She was ventilated for approximately one hour before she was responding appropriately. She was then extubated and the details of what occurred were explained to the patient. She was recovered in the PACU for another six hours before being sent to the ICU for further care. She had another orthopedic procedure performed during her stay and was discharged approximately 20 days after initial admission without further incident.
March 26, 2016 | Unregistered CommenterRamesh M. Singa
Interesting case, Ramesh. Obviously, we rely on the PACU personnel to alert us to post operative problems in sufficiently timely manner to allow intervention, as in your case, that is likely life saving. As for the seizures, it is more typical now for LAST to present 10-20 minutes after the block that it was when I trained 30 years ago. One thing that hasn't changed is the contribution of acidosis to increasing LA toxicity. It's possible here that the patient was hyperventilating and the resulting drop in pH exacerbated the effects of LA resulting in seizures. The total dose could be considered contributory as well. Regarding the somnolence after the seizure, did she receive naloxone at any point? it is very common for patients with LAST-related seizure treated with ILE to be completely alert shortly after the seizure stops. Your patient's somnolence was slow to resolve and this is a bit unusual.
April 10, 2016 | Registered Commenter[Guy Weinberg]