Two for One

Abstract

Combined spinal-epidural (CSE) analgesia is a frequently used method of labor analgesia. Although it is considered safe and effective, CSE can be complicated by local anesthetic systemic toxicity (LAST), a potentially life-threatening condition. We present a case of LAST that developed in a primigravida 50 minutes after uneventful placement of a CSE. Her symptoms resolved within 10 minutes of administering intralipid emulsion. She subsequently underwent cesarean delivery under spinal anesthesia for failure to progress without sequelae in the mother or infant. LAST in pregnancy can occur at traditionally subthreshold dosing; anesthesiologists must be vigilant to ensure prompt and effective treatment.

Intravenous lipid emulsion for local anaesthetic systemic toxicity in pregnant women: a scoping review

“…Seven women were full-term (≥ 37 weeks’ gestation) [ 33 – 38 , 40 ], four were preterm (< 37 weeks’ gestation) [ 23 , 29 , 38 , 41 ] and eleven were of unknown gestational age when LAST occurred [ 23 , 29 , 39 , 42 – 44 ]. Six women had pre-existing or pregnancy-induced medical conditions [ 34 , 35 , 37 , 38 , 41 ]; three were healthy [ 29 ]; and medical conditions were not reported for the rest. LAST occurred during pregnancy ( n = 1), during labour and birth ( n = 8) or after birth ( n = 13; Table 3 ).…”

“…Anaesthetic procedures causing LAST, in order of prevalence, included bilateral transverse abdominal plane (TAP) block ( n = 11) [ 23 , 29 , 35 , 38 – 41 ], epidural top-up anaesthesia for caesarean section ( n = 2) [ 33 , 37 ], epidural analgesia for labour ( n = 2) [ 29 , 36 ], spinal for caesarean section ( n = 1) [ 29 ], combined spinal–epidural for labour ( n = 1) [ 34 ], perineal nerve block for third-degree tear ( n = 1) [ 29 ] and infiltration anaesthesia for foetal thoracentesis ( n = 1). In series of procedures during pregnancy, labour and birth, and immediately after birth, the most commonly reported anaesthetic drug used was bupivacaine ( n = 18), followed by ropivacaine ( n = 9); these were administered alone, in combination with others, or preceding or following another local anaesthetic drug.…”

“…Of the causes reported ( n = 10), the most frequently cited was drug overdose ( n = 3) [ 23 , 29 , 38 ], Although not reported by the original authors, we identified one more case of an overdose in which the patient received a local anaesthetic dose exceeding the maximum recommended dose for an adult [ 40 ]. Both intravascular migration of the epidural catheter [ 29 , 34 , 37 ], and wrong route drug errors [infusions containing bupivacaine were accidentally connected to peripheral venous lines] ( n = 3) [ 29 , 42 – 44 ], were mentioned in 3 reports each, followed by unintentional partial intramuscular injections of a local anaesthetic ( n = 1) [ 38 ]. In most cases, assessing drug overdosage was impossible because of the lack of information about the patient’s weight, the use of epinephrine or adrenaline (which reduces systemic absorption and maximum plasma concentrations of a local anaesthetic) [ 23 , 29 , 35 – 38 , 40 , 42 , 43 ] or dose of local anaesthetic used [ 41 ].…”

“…All cases but one reported signs of neurologic toxicity; of these, 12 patients progressed to severe symptoms including seizures, loss of consciousness, apnoea and respiratory arrest [ 23 , 29 , 33 , 35 , 37 , 38 , 41 – 44 ] with seizure the most frequently reported ( n = 11) [ 23 , 29 , 35 , 37 , 38 , 41 – 44 ]. Eleven patients experienced cardiovascular toxicity symptoms [ 23 , 29 , 33 , 34 , 36 , 37 , 43 , 44 ]. Of these, the most commonly reported were tachycardia ( n = 6) [ 23 , 29 , 34 , 36 , 37 ] and hypertension ( n = 5) [ 23 , 29 , 34 , 36 , 37 ].…”

Local Anesthetics and Steroids: Contraindications and Complications - Clinical Update

“…Functional changes during pregnancy with influence of hormones on cardiac myocytes, increased neuronal sensitivity to LAs and engorged epidural veins contribute to higher risk for LAST. LAST in an expectant mother who received bupivacaine in combined spinal-epidural analgesia for labor started fifty minutes from the first LA administration ( 24 ). She felt metallic taste, tinnitus and palpitations.…”