An unusual toxic reaction to axillary block by mepivacaine with adrenaline

Abstract

An increase in blood pressure, accompanied by atrial fibrillation, agitation, incomprehensible shouts and loss of consciousness, was observed in an elderly, ASA classification group II, cardiovascularly medicated male, 12 min after performance of axillary block with mepivacaine 850 mg containing adrenaline 0.225 mg, for correction of Dupuytren's contracture. After intravenous administration of labetalol, metoprolol and midazolam the patient's condition improved, and 15 min later he woke up. The block was successful and surgery was conducted as scheduled despite persisting atrial fibrillation. Postoperatively, the patient refused DC cardioversion and was treated medically. Both the temporal relationship of events and the response to treatment suggest that a rapid systemic absorption of mepivacaine with adrenaline and/or interaction of these drugs with the patient's cardiovascular medications were responsible for the perioperative complications.

Comparison of transarterial and multiple nerve stimulation techniques for axillary block using a high dose of mepivacaine with adrenaline

“…They received 14.1, 16.4 and 6.5 mg kg ª1 of MEPA, respectively. The first two patients were probably overdosed, the symptoms in the third patient could have been enhanced by the concurrent psychiatric illness, whereas in the fourth patient who received 10.9 mg kg ª1 the clinical picture suggests interaction of his cardiovascular medication with adrenaline (8).…”

“…After intravenous administration of labetalol, metoprolol and midazolam his condition improved and he woke up 15 min later. He was subsequently excluded from data analysis and is a subject of a recently published case report (8). Another patient in this group, an obese, depressive female (130 kg) became lightheaded, agitated, hypertensive and reported whole body numbness 18 min after block performance.…”

“…Transarterial injections (TA) of 750-900 mg ligno-or mepivacaine are simple, very successful (99-100%) and free from adverse effects (5,6). However, other reports suggest that high doses of mepivacaine with or without adrenaline may produce high plasma levels and signs and symptoms of toxicity (7,8), while the recommended doses do not have satisfactory success rates (9,10). Multiple nerve stimulations (MNS) are 88-93% effective, increasing to 98-100% after supplementation, when using recommended doses of mepivacaine, that is AE7 mg kg ª1 (10)(11)(12).…”

Single-Injection Brachial Plexus Anesthesia for Arteriovenous Fistula Surgery of the Forearm: A Comparison of Infraclavicular Coracoid and Axillary Approach

“…Similar complications have been reported before. 6,7 In our study, the total dose of epinephrine was relatively large, 168 to 240 g (i.e., larger than suggested by Raj and coworkers 8 as the maximum recommended dose of 1.5 g/kg/10 min). Intravascular injection of the local anesthetic solutions, a possible complication of both the axillary and the lateral infraclavicular approaches, 4,9,10 did not occur in our patients.…”