T he authors believe this is the first report of the successful use of lipid emulsion (Intralipid) in a prearrest situation and the first of cardiac arrhythmia and cardiovascular collapse following levobupivacaine administration in a peripheral nerve block. The 75-year-old ASA III woman presented for repair of a fractured femur, with a history of severe chronic obstructive pulmonary disease.With a normal preoperative electrocardiogram (ECG), a lumbar plexus block was begun at L4, after several unsuccessful attempts to place a subarachnoid block. Following negative aspiration, levobupivacaine 0.5% was injected slowly to a total of 20 mL; aspiration continued to be negative. Within seconds, the woman became unresponsive, followed by tonic-clonic convulsions, and a presumptive diagnosis of local anesthetic toxicity due to intravascular injection of levobupivacaine was made. Continuous, lead II ECG traces demonstrated deteriorating QRS morphology with reduced voltage and broadening complexes. Carotid pulse remained palpable and a second convulsion occurred 2 minutes after the first one. An intravenous bolus of metaraminol 0.5 mg was given and the airway secured with propofol and suxamethonium. Within 4 minutes of levobupivacaine injection, Intralipid 20% solution (100 mL) was infused over 5 minutes via the peripheral cannula, resulting in a rapid normalization of QRS morphology and no more convulsions. The patient's hemodynamics and ECG traces remained stable and surgery proceeded with volatile anesthesia. She continued to improve and the surgery was uneventful, as was recovery.Lipid emulsion has been used successfully to treat local anesthetic-induced cardiovascular collapse in animals and in 2 cases of cardiac arrest in humans. Cardiac arrest has been reported following intrathecal spread of local anesthetic during posterior lumbar plexus block and generalized tonic-clonic seizures have been seen in a 27-yearold patient following presumed intravenous injection of levobupivacaine, but with no ECG abnormalities or cardiovascular instability. There also have been reports of central nervous system toxicity and seizures following accidental intravascular injection of levobupivacaine. With reports of beneficial effects of Intralipid administration in local anesthetic toxicity, the authors have placed Intralipid in all theater areas for rapid accesses. They recommended continuing collection of reported uses of this lipid emulsion, both successful and unsuccessful, to reach a consensus on its efficacy and appropriateness.

The EQ-5D index is less responsive than instruments specific to pain measurement, although it is capable of indicating clinically important changes. The lower responsiveness arises from EQ-5D's more limited gradation of severity and its multidimensionality.

Summary Lipid emulsion has been used in the successful treatment of local anaesthetic‐induced cardiovascular collapse in animals and in two cases of cardiac arrest in humans. Previous reports of levobupivacaine toxicity in humans have been characterised by neurological signs and symptoms, without serious cardiovascular events. We present a case in which presumed intravenous injection of levobupivacaine led to neurological and cardiovascular consequences. This was treated successfully by resuscitation that included intravenous Intralipid® infusion.

. (2015) Visuospatial ability as a predictor of novice performance in ultrasound-guided regional anesthesia. Anesthesiology, 123 (5 A note on versions:The version presented here may differ from the published version or from the version of record. If you wish to cite this item you are advised to consult the publisher's version. Please see the repository url above for details on accessing the published version and note that access may require a subscription. Conflicts of Interest:Professor Jonathan G Hardman:He is an editor of British Journal of Anesthesia. Eamonn Ferguson:He was a principle-investigator on a case award grant from the ESRC (Integrating Prospect theory