Post Your Cases > Dr Marika Edelsten (SHO)

60 year old lady, history of osteoarthritis, had left and right knee replacements, all under general anaesthetic (no local anaesthetic) and a failed epidural during labour approx 30 years earlier. No known allergies, otherwise fit and well. Due to have a brachial plexus block (with interscalene approach) for subcromial decompression of right shoulder.
Locum Consultant present. Procedure explained and aseptic technique used. Used stimuplex to identify brachial plexus at the posterior aspect of the sternocleidomastoid. Contractions were produced in pectoralis and deltoid at 1.5mAmp and still present at 0.5mAmp. Levobupivicaine 0.5% was used. Aspirated and injected, 1ml was sufficient to ablate contraction. Aspiration was performed every 5ml of LA injected. After 22ml was injected, patient became unresponsive, frothing at the mouth, apnoeic and had grand mal seizure. Stopped injecting the LA, administered 100% oxygen, manually ventilated (sats had dropped to 85%). ST depression in lead II on anaesthetic monitor and BP approx 190/110mmHg. Administered 70mg propofol and seizures ceased approx 10s after administration. Saturations improved to 100%, BP normalised and ST depression improved. Patient became responsive after approx 5 mins. Able to respond and obey commands. In view of parameters stabilising, the anaesthetic was continued with propofol induction, fentanyl and muscle relaxant for intubation. The subsequent anaesthetic was uneventful. Post-operatively the patient was pain free. Admitted overnight for observation with no relapse of seizures. The next day she went home.

No intralipid was administered

September 28, 2007 | Unregistered CommenterDr Marika Edelsten, University Hospital Lewisham
dr. edelsten, thank you for sharing the case....your post embodies the spirit and purpose of the site since it's by this type of reporting that we will all learn. i believe the main things you did to prevent progression to a potentially catastrophic result were: quick response with an emphasis on airway management (read, oxygenation and ventilation) and seizure suppression (this aids in preventing acidosis, an important factor in exacerbating LA toxicity).statistical analysis has suggested that about 1:10 patients experiencing seizure will progress to cardiac arrest. this was all in keeping with the AAGBI guidelines which i hope you have seen.

i have no problem with not giving the lipid (pls, use generic terms as i don't want to give big pharma any free advertising, they don't need it and they don't support my research). however, i would have at least wanted to have it drawn up and ready to go. some would argue to give one bolus prophylactically at that point and i would have no argument with that either. regardless, i'm so glad everything turned out well. you did all the right things. congrats to you. i wonder if you had read the AAGBI laminate and if that guided your response at all. if so, we can count your case as save #1 and also send congrats to dr. harrop-griffiths, picard, meeks, denny, et al who contributed.
guy
September 30, 2007 | Registered Commenter[Guy Weinberg]