Post Your Cases > Bilateral TAP Blocks Delayed PACU Seizure?
My 40 y/o female patient had a history of bradycardia with unexplained episodes of “dizziness and blackouts”. She had seen a cardiologist within the last year. She describes wearing a Holter monitor for 24 hours and was told “there’s nothing wrong with your heart”. She presented to an ASC for a single site laparoscopic supracervical hysterectomy.
The patients HR in preop holding was 49 beats/min. She was thin. She denied being a runner or someone that pursued other forms of cardiovascular fitness. Upon further questioning, she had gone nearly a year without a “fainting spell” but recently experienced one a few weeks prior to the surgical date.
Prior to induction of GA I pretreated the bradycardia with glycopyrrolate to get HR in low 60’s. The case was uneventful. The surgeon requested TAP blocks for post-op analgesia. Under GETA, I injected bupivicaine 0.25% with epinephrine 1:200k 30 ml each side (total of 60 mls). The dose equates to bupivicaine 2.5 mg/kg (within the acceptable “safe” margins from most authorities on bupivicaine dosing). Ultrasound was used to confirm placement of the LA just deep to the fascism layer between the internal oblique and the transversus abdominus muscle. A subcostal approach was used with a hydro dissection caudal/posterior technique to maximize dermatomal coverage. Normal and expected expansion of LA pocket was created. In other words, I do not believe significant volume of LA was place intravascularly.
The patient was successfully extubated without incident and taken to PACU alert and oriented. I left the facility approximately 15-20 minutes after the placement of the TAP blocks. About 10 minutes later (30 min post-TAP Blocks) the PACU RN callee to ask me to return to the ASC immediately as the patient was unresponsive and “twitching or seizing”. I instructed her to hang intralipid and “open it up” as I was only about 3 minutes away. When I arrived the RNs were assisting respirations with an Ambubag and the patient was unresponsive and twitching all extremities as described. There was no significant EKG abnormalities. I saw NSR. The RN reported she witnessed a single “cardiac pause” that last a couple seconds. She also reported around the time the twitching started the HR had become bradycardic in the high 40’s BPM (same as pre-op) and have the additional glycoprrolate I had written in my orders for bradycardia.
While awaiting EMS, in an effort to protect the airway, I reintubated the patient with Midazolam 4 mg and Sux (NIBP unobtainable given twitching motion). I did not want to exacerbate a potentially hypotensive patient’s BP with Propofol or exacerbate seizure-like activity with Etomidate. There was some question in all of the Healthcare workers minds as to the true nature of the “twitching”. Was it truly seizure activity? Was it LA toxicity? Was it related her “blackouts” and bradycardia? The patient did have clear decerabrate posturing just prior to reintubation. The twitch did lessen after the midazolam. The intralipid bag of 20% 250 ml? Was completely infused. (Significantly more than recommended dosing for LA toxicity). EMS arrived and transferred patient to a nearby inpatient facility.
The ER physician called me to clarify the account of transpired events. After telling him he relayed to me that patient was alert and biting on ETT on arrival. She was extubated. He felt her history, events were consistent with a vasovagal episode.
I don’t regret treating her as possible LA toxicity. But I’m interested in hearing this forum’s opinion on this case.
The patients HR in preop holding was 49 beats/min. She was thin. She denied being a runner or someone that pursued other forms of cardiovascular fitness. Upon further questioning, she had gone nearly a year without a “fainting spell” but recently experienced one a few weeks prior to the surgical date.
Prior to induction of GA I pretreated the bradycardia with glycopyrrolate to get HR in low 60’s. The case was uneventful. The surgeon requested TAP blocks for post-op analgesia. Under GETA, I injected bupivicaine 0.25% with epinephrine 1:200k 30 ml each side (total of 60 mls). The dose equates to bupivicaine 2.5 mg/kg (within the acceptable “safe” margins from most authorities on bupivicaine dosing). Ultrasound was used to confirm placement of the LA just deep to the fascism layer between the internal oblique and the transversus abdominus muscle. A subcostal approach was used with a hydro dissection caudal/posterior technique to maximize dermatomal coverage. Normal and expected expansion of LA pocket was created. In other words, I do not believe significant volume of LA was place intravascularly.
The patient was successfully extubated without incident and taken to PACU alert and oriented. I left the facility approximately 15-20 minutes after the placement of the TAP blocks. About 10 minutes later (30 min post-TAP Blocks) the PACU RN callee to ask me to return to the ASC immediately as the patient was unresponsive and “twitching or seizing”. I instructed her to hang intralipid and “open it up” as I was only about 3 minutes away. When I arrived the RNs were assisting respirations with an Ambubag and the patient was unresponsive and twitching all extremities as described. There was no significant EKG abnormalities. I saw NSR. The RN reported she witnessed a single “cardiac pause” that last a couple seconds. She also reported around the time the twitching started the HR had become bradycardic in the high 40’s BPM (same as pre-op) and have the additional glycoprrolate I had written in my orders for bradycardia.
While awaiting EMS, in an effort to protect the airway, I reintubated the patient with Midazolam 4 mg and Sux (NIBP unobtainable given twitching motion). I did not want to exacerbate a potentially hypotensive patient’s BP with Propofol or exacerbate seizure-like activity with Etomidate. There was some question in all of the Healthcare workers minds as to the true nature of the “twitching”. Was it truly seizure activity? Was it LA toxicity? Was it related her “blackouts” and bradycardia? The patient did have clear decerabrate posturing just prior to reintubation. The twitch did lessen after the midazolam. The intralipid bag of 20% 250 ml? Was completely infused. (Significantly more than recommended dosing for LA toxicity). EMS arrived and transferred patient to a nearby inpatient facility.
The ER physician called me to clarify the account of transpired events. After telling him he relayed to me that patient was alert and biting on ETT on arrival. She was extubated. He felt her history, events were consistent with a vasovagal episode.
I don’t regret treating her as possible LA toxicity. But I’m interested in hearing this forum’s opinion on this case.