Post Your Cases > Intralipid Treatment of Bupivicaine Toxicity in Sciatic Block

58 yo 65 kg lady for right TKA. She only has a history of hypertension. No history of CAD. After being sedated with Versed 4 mg she was placed in the LL postion, a posterior sciatic nerve block was performed with Bupivicaine 0.5% 30 ml. No blood was aspirated after 3 ml intermittant injections. She was conversant during the block. Immediately after the block when I asked her to turn supine, she was unresponsive. She quickle progressed to seizures and ventricular fibrillation. CPR was immediately started and Lipid emulsion was given within 30 seconds, 100 ml and a continuous infusion started. Before the defibrillator could get to the bed, she converted to sinus rhythym, but without a pulse. However her oxygen saturation improved radidly from the low 80s to 97% with bag valve mask ventilation. (She soon after this was intubated.) Epinephrine 1 mg was given along with CPR. She then had a bradycardia of 20 bpm for 1 minute then resumed sinus rhythym of 90 bpm. At this time she had a pulse, but no recordable blood pressure. Epinephrine 1 mg was given again. (She had Valium 10 mg during the CPR for her seizures) After the 2nd Epinephrine she had a pulse with a blood pressure of 220/120. She stablized with her vital signs and did not need furthur support other than ventilation. The Lipid infusion finished over 20 minutes. Since we do not have access to immediate heart by-pass Rx, we have Lipid Emulsion at the bed side during our blocks. I believe the immediate infusion prevented a permanant nonreversible heart rhythym for this lady.
March 13, 2008 | Unregistered CommenterTom Barlow, MD
Tom,
thanks very much for the post. we're going to call this one
"CHEMICAL DEFIBRILLATION!".
anyway, it's quite a save -and very nicely done.
i would guess the delay in recovery of blood pressure had to do with the time required for circulation of the resuscitation meds. my experience with lipid and open chest cardiac massage in dogs is that myocardial wall tension returns just as the coronary bed flashes white from the lipid. at that point you can feel the ventricle go from flaccid to firm and shortly thereafter it begins contracting briskly. obviously circulation time is impaired at the outset of LA toxicity, so its mostly up to us to get the drug where it needs to go by good chest compressions.
again, kudos for a great save. how is she doing now?
btw, if you have ECG strips you might consider writing this up given that she converted spontaneously after the lipid infusion.
guy
March 13, 2008 | Registered Commenter[Guy Weinberg]
She was extubated 18 hours after the event. No signs of aspiration noted. She appears neurologically intact, but communication problems since she is chinese is clouding the assessment. Family has spoken with her and they cannot detect any problems. No signs of sciatic nerve block are present today and none were noted during her neuro checks in the ICU last night. I am looking for any EKG strips taken during the resussictation. A case report in RAPM this month by Dr Gerancher et al is amazingly similar.
March 14, 2008 | Unregistered CommenterTom
There were no EKG strips from the code. She is discharged today , planning on surgery this next week with blocks. (her preference)
March 18, 2008 | Unregistered CommenterTom