Recurrence of Cardiotoxicity After Lipid Rescue from Bupivacaine-Induced Cardiac Arrest

Abstract

Accidental intravascular administration of bupivacaine during performance of a brachial block precipitated convulsions followed by asystole. The patient was rapidly resuscitated using cardiopulmonary resuscitation, supplemented by 150 mL of 20% lipid emulsion. Nonetheless, cardiac toxicity reappeared 40 min after completion of the lipid emulsion. In the absence of further lipid emulsion, amiodarone and inotropic support were used to treat cardiotoxicity. This case suggests that local anesthetic systemic toxicity may recur after initial lipid rescue. Since recurrence of toxicity may necessitate administration of additional doses of lipid emulsion, a sufficient quantity of lipid emulsion should be available when regional anesthesia is performed.

Treatment of Pieris Ingestion in Goats with Intravenous Lipid Emulsion

“…The most promising is the lipid sink theory in which plasma lipid acts as a compartment that sequesters the lipophilic compounds. Lipid micelles are eventually taken up and stored in lysosomes in skeletal muscle, myocardium, and abdominal viscera, where they are no longer biologically available [3,11]. However, plasma lipid post-ILE is not theoretically adequate to create an effective depot for lipophilic compounds [12].…”

“…It is possible that ILE can interfere with lipophilic drugs used therapeutically [5,9]. Recurrence of clinical signs after cessation of ILE therapy has also been reported [11]. Many common veterinary drugs are lipophilic and thus could potentially be affected by ILE.…”

Lipid rescue: the use of lipid emulsions to treat local anaesthetic toxicity

“…8,49 Practitioners are frequently uncertain of the dose of lipid emulsion to be administered during resuscitation. 50 To prevent such uncertainty, both Weinberg 8 and the AAGBI 49 have recommended that dosing instructions should be attached to the stock of lipid held for treating local anaesthetic toxicity.…”

“…50 Reoccurrence of toxicity may have many causes. Serum concentrations of lipid may decrease due to redistribution and metabolism.…”

“…A recent case report observed an increase in serum amylase after lipid rescue, a possible indication of pancreatic injury. 50 However, no other complications of lipid emulsion therapy after local anaesthetic toxicity have been reported yet. None of the aforementioned potential complications, with the possible exception of known allergy, should deter lipid administration in the presence of local anaesthetic-induced cardiac arrest.…”