Awake infant spinal with isobaric bupivacaine 0.5% 0.95 mg/kg performed. Baby had progressive bradycardia to 50 BPM and went into complete heart block despite multiple doses of epinephrine. Turned dusky and gray, but remained awake and crying. No seizure. Was intubated and received CPR and intralipid 1.5mL/kg x2 then infusion.
Had absolutely no response to intralipid. No improvement at all.
Cannulated to ECMO x48 hours. Eventually made a complete neurologic recovery. Is now 7 months old.
Later found this paper: Hiller DB, Gregorio GD, Ripper R, Kelly K, Massad M, Edelman L, Edelman G, Feinstein DL, Weinberg GL. Epinephrine impairs lipid resuscitation from bupivacaine overdose: a threshold effect. Anesthesiology. 2009 Sep;111(3):498-505. doi: 10.1097/ALN.0b013e3181afde0a. PMID: 19704251.
I believe the epinephrine doses inhibited the intralipid response. Luckily ECMO was immediately available.
Had absolutely no response to intralipid. No improvement at all.
Cannulated to ECMO x48 hours. Eventually made a complete neurologic recovery. Is now 7 months old.
Later found this paper: Hiller DB, Gregorio GD, Ripper R, Kelly K, Massad M, Edelman L, Edelman G, Feinstein DL, Weinberg GL. Epinephrine impairs lipid resuscitation from bupivacaine overdose: a threshold effect. Anesthesiology. 2009 Sep;111(3):498-505. doi: 10.1097/ALN.0b013e3181afde0a. PMID: 19704251.
I believe the epinephrine doses inhibited the intralipid response. Luckily ECMO was immediately available.