Journal: Anesth Analg 106(5):1572-1574, 2008
Reprint: Pediatric Anesthesia Unit, American Memorial Hospital, CHU Reims, F-51092, France
Faculty Disclosure: Abstracted by T. Tilton, who has nothing to disclose.
A case is reported of a 13-yr-old female, 55 kg, ASA PS 1, scheduled for meniscectomy of her left knee under general anesthesia and lumbar plexus block. She was medicated preoperatively with oral hydroxyzine; general anesthesia consisted of sevoflurane in oxygen and nitrous oxide followed by placement of an intravenous catheter infused with 0.9% saline at 10 mL/kg/hr. Lumbar plexus block was placed with an 18-ga insulated needle and neurostimulator. Test dosing after negative aspiration was with a mixture of 1 mL 1% lidocaine with epinephrine (1/200,000) and 1 mL 0.75% ropivacaine; the patient's vital signs remained stable. The same solution was injected in 3 mL doses over a 2-minute period, total 20 mL, followed by placement of a 20-ga catheter.
Fifteen minutes later, ventricular tachycardia occurred spontaneously at 150 beats/min with wide QRS complexes. Arterial blood pressure increased from 88/45 mmHg to 120/92 mmHg and oxygen saturation declined from 99% to 92%; end-tidal carbon dioxide was unchanged. Sevoflurane was decreased to 1%, nitrous oxide was discontinued, and because local anesthetic toxicity was sus¬pected, 150 mL (3 mL/kg) of 20% lipid emulsion was injected over 3 minutes. Within 2 minutes, the patient's heart rate decreased to 100 beats/min, blood pressure to 100/48 mmHg, and saturation to 97% and ECG reverted to normal sinus rhythm with persistent ST depression, which disappeared after 30 min. Surgery was completed without sequelae. Two hours after injection, a repeat blood sample showed that ropivacaine/lidocaine concen¬trations had decreased from 872/648 ng/mL to 494/360 ng/mL, respectively. The perineural cathe¬ter was removed at surgery's end. The postop¬erative course was uneventful.
The authors noted that the 15-minute delay between injection and arrhythmia is more consistent with rapid absorption rather than direct IV injection of the local anesthetic. They recommend that 20% lipid emulsion be stored with other emergency drugs in anesthesia areas where local anesthetics are administered. |
