I have been performing blocks for over 23 years. My first LA toxicity case occurred about a year ago, before I was aware of the use of Intralipid. In the last two weeks I had two cases. Luckily for me and my patients I had noted the article regarding the use of Intralipid in the APSF Summer 2007 newsletter and subsequently read the Case report by Rosenblatt et al.
Case 1: 71 year old female for a shoulder manipulation under anesthesia at a free standing orthopedic surgery center. After full monitoring and administration of o2 by nasal canulae, the patient was sedated with fentanyl and versed. A left interscalene block was placed in the usual manner without difficulty using a pro block 22g needle with a nerve stimulator. Frequent aspiration on the needle was negative, and the resistance to injection was normal. A total of 20ml of 1/2% ropivicaine and 20 ml of 1.5% lidocaine was used. Approximately one minute post injection the patient had a grand mal seizure. Immediate control of the airway was instituted with o2/ambu/mask/oropharyngeal airway. The patient had adequate pulses but the ECG demonstrated wide complex sinus tachycardia with a rate between 130-150/minute.
The patient was given a bolus of Intralipid 20%, 200 ml by rapid infusion, as well as versed 2mg. Within two minutes of the bolus, the ECG morphed into normal complex sinus tachycardia with a rate of 110-120. The seizure stopped as well. The patient continued to be apneic and was well ventilated by mask/ambu/o2. The heart rate gradually went down to 90/minute. The remainder of the Intralipid, about 50cc, was infused at a slow rate. Twenty five minutes later the patient had another grand mal seizure which was quickly controlled with Propofol 70 mg. At this point the patient was intubated and ventilation was continued for about an hour after which time she awoke and had purposeful movement. She was stable during this period of time and subsequently extubated. No further instability was noted. However she exibited CNS irritability and confusiuon. She was admitted to the local hospital via an EMS transport for further observation and was discharged to home in good condition about 6 hours after admission with no ill effects from her ordeal.
Case 2:
Patient was a 71 yo female at our surgery center for an arthroscopic acromioplasty. Similar to the last patient described she underwent an interscalene block. A minute or so after the block was completed she had a grand mal seizure. The airway was managed with ambu/mask/o2/oropharyngeal airway and Intralipid was immediately hung and bolused. Versed 4 mg was given and the seizure stopped in approximately 4 minutes. No cardiovascular instability was noted and the patient began breathing without assistance and woke up within ten minutes of the seizure's onset. After being observed for another 30 minutes she was deemed to be stable enough to undergo the surgery which was accomplished without incident. The patient was discharged to home 90 minutes after the completion of the surgery in good condition.
I must say that I am most impressed with how well the Intralipid worked in both of these cases. I hope that I have now obtained enough practice in treating LA toxicity that Murphy's law will act in reverse so that it never happen again. However, I will always make sure that I have Intralipids close by when I perform blocks.
Case 1: 71 year old female for a shoulder manipulation under anesthesia at a free standing orthopedic surgery center. After full monitoring and administration of o2 by nasal canulae, the patient was sedated with fentanyl and versed. A left interscalene block was placed in the usual manner without difficulty using a pro block 22g needle with a nerve stimulator. Frequent aspiration on the needle was negative, and the resistance to injection was normal. A total of 20ml of 1/2% ropivicaine and 20 ml of 1.5% lidocaine was used. Approximately one minute post injection the patient had a grand mal seizure. Immediate control of the airway was instituted with o2/ambu/mask/oropharyngeal airway. The patient had adequate pulses but the ECG demonstrated wide complex sinus tachycardia with a rate between 130-150/minute.
The patient was given a bolus of Intralipid 20%, 200 ml by rapid infusion, as well as versed 2mg. Within two minutes of the bolus, the ECG morphed into normal complex sinus tachycardia with a rate of 110-120. The seizure stopped as well. The patient continued to be apneic and was well ventilated by mask/ambu/o2. The heart rate gradually went down to 90/minute. The remainder of the Intralipid, about 50cc, was infused at a slow rate. Twenty five minutes later the patient had another grand mal seizure which was quickly controlled with Propofol 70 mg. At this point the patient was intubated and ventilation was continued for about an hour after which time she awoke and had purposeful movement. She was stable during this period of time and subsequently extubated. No further instability was noted. However she exibited CNS irritability and confusiuon. She was admitted to the local hospital via an EMS transport for further observation and was discharged to home in good condition about 6 hours after admission with no ill effects from her ordeal.
Case 2:
Patient was a 71 yo female at our surgery center for an arthroscopic acromioplasty. Similar to the last patient described she underwent an interscalene block. A minute or so after the block was completed she had a grand mal seizure. The airway was managed with ambu/mask/o2/oropharyngeal airway and Intralipid was immediately hung and bolused. Versed 4 mg was given and the seizure stopped in approximately 4 minutes. No cardiovascular instability was noted and the patient began breathing without assistance and woke up within ten minutes of the seizure's onset. After being observed for another 30 minutes she was deemed to be stable enough to undergo the surgery which was accomplished without incident. The patient was discharged to home 90 minutes after the completion of the surgery in good condition.
I must say that I am most impressed with how well the Intralipid worked in both of these cases. I hope that I have now obtained enough practice in treating LA toxicity that Murphy's law will act in reverse so that it never happen again. However, I will always make sure that I have Intralipids close by when I perform blocks.
Thanks for having such an informative web site.