LipidRescue™ Resuscitation

A 70 yr old (ASA 2) lady presented for Right Total Knee replacement.No history of siezures, just well controlled hypertension.

Anaesthesia consisted of a spinal anaesthetic supplemented by a single shot sciatic block and a continous lumbar plexus catheter. This is my standard anaesthetic for such cases.

The patient was placed in the left lateral position. The patient was given 2mg midazolam but was chatting appropraitely the whole way through the blocks. Sciatic block was performed fist. Labatt approach to 0.5mA with 100mmm stimuplex needle and 20ml plain 0.5% levobupivacaine injected with negative aspirationevery 5 mls. Then the spinal at L3/4 with 2.2mls 0.75% plain levobupivacaine. Finally the lumbar plexus block (Capdevila modification of the Winnie Approach) using a 100 mm 19G pajunk plexus catheter kit. Plexus located to 0.5mA , then slow injection of 20mls 0.5% levobupivacaine plus 1/200,000 adrenaline. Negative aspiration for blood every 5 mls and no change in heart rate. Then 3 mins later, during insertion of the plexus catheter, verbal contact was lost and generalised siezure activity noted.

The patient was turned supine, high flow face mask O2 given and 1ml/kg of intralipid was administered within 2 mins by second anaesthetist summoned by the emergency buzzer. First NIBP was 110/70, HR 98 sinus rhythm. Fitting stopped almost immediately and patient was breathing spontaneously. The patient regained consciousness 5 mins later. Surgery postponed for 1 week. No sequelae.

The three blocks were performed relatively quickly and this may represent a too rapid rise in plasma concentration of LA. This is my first such case in many hundreds of patients recieving this anaesthetic technique.

Johnathan, Thanks very much for the excellent case description. First, your experience with respect to frequency (first such case in many hundreds) is right on target as the best estimates put the incidence of seizures during peripheral nerve block at about 1:500. Your report also makes the case for early intervention. Is there logic to waiting for cardiac arrest and 20 minutes of ACLS so that you can say all alternative therapies were exhausted before LipidRescue? Perhaps so, a year or more ago. But with 6 published cases, several more posted here and many others by word of mouth (from those too shy to post), I feel far more confident of the efficacy and safety and therefore more confident recommending LipidRescue as a means to prevent progression to more ominous symptoms of LA toxicity.