Post Your Cases > Successful lipid rescue for bupivacaine toxicity

I just saw that I could post a case on this site from a question I answered on MOCA minute. I do not have immediate access to the full history and I am not going to post my name or put any other information that could be used to identify me and I am not going to respond to email inquiries since this would reveal my name. Suffice it to say that a very obese woman was getting a femoral nerve block following a total knee arthroplasty, using 40 ml of 0.5% bupivacaine with 1:200,000 epinephrine. The block was done slowly using ultrasound and gentle aspiration was done every 5 ml. Just as the last 5 ml of local was being injected, the patient lost consciousness and became apneic, quickly followed by seizures, quickly followed by what appeared to be pulseless V-tach although since chest compressions were going on it was uncertain to know exactly what rhythm she was in. She was treated with mask ventilation and chest compressions. Mask ventilation was difficult because of her obesity and because she was seizing. Intubation was accomplished following succinylcholine. We had Intralipid in our block cart and this was started within a couple of minutes. We just ran it in as fast as it would go and didn't worry about an exact dose. Within a couple minutes more, the patient was in sinus rhythm and had a pulse. She was unconscious for over an hour and I was very worried about neurological damage, but she ultimately fully awakened but was kept on the ventilator for several days by our ICU docs, who had never seen a case of this before. Anyway, I strongly believe that without the lipid rescue this woman would have quickly died.
May 1, 2016 | Unregistered CommenterAnesthesia Bob
Thanks, Bob, for the impressive case. Two quick questions:
Did you deliver a bolus or just brisk infusion?
What was the total dose of lipid delivered?
I'm very glad you managed the patient so expertly and that everything turned out well.
November 1, 2016 | Registered Commenter[Guy Weinberg]