Post Your Cases > Successful use of Intralipid for LAST after nurse mistakenly bolused epidural bupivacaine infusion bag directly intravenously.

Shortly after successful epidural placement and negative test dose in a healthy 21 year old parturient, the patient began experiencing perioral numbness and tinnitus shortly followed by stupor, seizure, hypotension, and tachycardia. The puzzling factor is that nothing had been bolused via epidural other than the test dose of 3 ml 1.5% Lidocaine which was negative only minutes prior. It was quickly noticed that the OB nurse had mistakenly grabbed the epidural infusion bag (100 ml 0.25 % Bupivacaine with 2 mcg/ml Fentanyl) thinking it was Penicillin and bolused all of it IV. 150 ml of 20% Intralipid was bolused IV and the patient's BP and mentation improved within a matter of approximately 2-3 min. Intralipid infusion was then initiated at 0.25 ml/kg/min for 15 minutes post return of normal systemic blood pressure. The patient never required CPR as she was tachycardic (HR 150's) with pulse and perfusing BP (although low w/ SBP in 60's). Patient was apneic momentarily (less than 2 minutes) and maintained oxygen saturation > 90% throughout. Fetal Heart Rate never dropped below 130 and the patient delivered a healthy singleton approximately 5-10 min post resuscitation with APGAR's 9 at 1 min, and 9 again at 5 min. It was prompt recognition followed by prompt administration of intralipid that saved this girl and her fetus' life.
July 17, 2016 | Unregistered CommenterDr. Kyle Nester
Thanks, Kyle for posting this impressive case. Note that the standard 'maximum recommended doses' for various LA are entirely meaningless for an intravascular injection, where depending on the patient, site and speed of injection even small quantities (<100mg) of bupivacaine can be fatal. Your patient received a rapid bolus of 250mg bupivacaine and she and baby survived! This is the type of case that makes us proud. Twenty years ago, the outcome might have been much different. The net effect of such a catastrophe in addition to the other, secondary victims (family and physician) would include the nurse responsible for the drug swap, with the attendant psychological and possible legal ramifications. I'm so glad to hear that everything turned out so well.
November 2, 2016 | Registered Commenter[Guy Weinberg]