Successful resuscitation of serious bupivacaine intoxication in a patient with pre-existing heart failure

Abstract

P Pu ur rp po os se e: : In dogs intoxicated with bupivacaine, clonidine is effective to treat conduction disturbances and dobutamine corrects myocardial depression. We report the case of a patient who experienced severe bupivacaine cardiotoxicity and who was treated successfully using these medications.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : In a patient with pre-existing heart failure a surgical procedure to fix a humeral fracture was necessary. Preoperatively, heart failure was controlled with transcutaneous nitroglycerin and iv deslanoside. A bupivacaine bolus was administred iv accidentally (a mixture of bupivacaine 75 mg, 15 µg clonidine). The patient developped nodal rhythm with extreme bradycardia, severe shock and convulsions. Seizures were controlled with thiopentone/succinylcholine. Epinephrine iv boluses (0.1 mg × 3) restored blood pressure (BP) to 50/30 mmHg and heart rate (HR) to 60 (nodal rhythm).Following 75 µg clonidine iv, BP rose to 90/70 and HR to 90 min. Cardiac rhythm reverted to sinus rhythm with first degree atrioventricular block. Echocardiography showed hyperkinesia and relative hypovolemia that was controlled with iv administration of terlipressin and glucagon. Subsequent dobutamine infusion stabilized hemodynamic conditions. It was decided to proceed with surgery using a midazolam/sufentanil based general anesthetic. In the intensive care unit, recovery, extubation and weaning from the dobutamine infusion were realized within 16 hr of the event.C Co on nc cl lu us si io on ns s: : In this patient with preoperative heart failure, clonidine was effective to treat bupivacaine induced conduction disturbances. Epinephrine and dobutamine were effective to treat myocardial depression and terlipressin effectively controlled vasodilatation.

Effects of Dexmedetomidine Pretreatment on Bupivacaine Cardiotoxicity in Rats

“…They noted that clonidine seemed to be effective at treating bupivacaine-induced conduction disturbances, whereas epinephrine and dobutamine were effective at treating the myocardial depression in this patient. 14 Dexmedetomidine is a highly selective > 2 -adrenoceptor agonist that is increasingly being used for intraoperative sedation or as an adjuvant to local anesthetics in regional anesthesia procedures. 2,5Y12 Intravenous administration of dexmedetomidine prolongs the duration of epidural anesthesia and provides sedation and analgesia with an acceptable rate of minor adverse effects.…”

Inadvertent epidural administration of insulin

“…One promising development is the production of non-interchangeable epidural and spinal catheter connectors that cannot be accidentally connected to intravenous lines [9,10]. Changing the calibre of connectors on all regional anaesthesia equipment to make them incompatible with the intravenous Luer system may also prevent the potentially life-threatening effects of the intravenous administration of drugs intended for neuraxial use [11,12]. The introduction of such a system may greatly enhance patient safety.…”

Successful Outcome of Cardiac Arrest Refractory to Advanced Cardiac Life Support Using Extracorporeal Membrane Oxygenation

“…There have been several reports of survival of bupivacaine toxicity thanks to the use of CPB [11][12][13]. Bupivicaine is a racemic mixture of levorotatory and dextrorotatory isomers, but its cardiotoxic properties are attributed to the dextrorotatory isomer.…”