Intravenous Lipid Infusion in the Successful Resuscitation of Local Anesthetic-Induced Cardiovascular Collapse After Supraclavicular Brachial Plexus Block

Abstract

We describe a case of successful resuscitation with an i.v. lipid infusion of local anesthetic-induced cardiovascular toxicity after supraclavicular brachial plexus block with mepivacaine and bupivacaine. Lipid therapy was initiated after 10 min of unsuccessful resuscitation and resulted in restoration of cardiovascular activity and hemodynamic stability. This case illustrates the utility of i.v. lipid therapy in the treatment of local anesthetic toxicity.

Hemodynamic changes in lipid emulsion therapy (SMOFlipid) for bupivacaine toxicity in swines

“…Until recently, it was a devastating complication without any specific treatment. Since 2006, with a publication on the successful use of lipid emulsion 11,12 to treat cardiotoxicity due to intravascular injection of local anesthetics, several formulations have been suggested for this purpose 13 . We chose to use the 20% SMOFlipid solution because there are few cases describing its use for this type of complication.…”

“…Rosenblatt et al 11 and later Litz et al 12 were the first to publish the successful use of LE in the treatment of cardiac arrest due to local anesthetics, when conventional resuscitative techniques had failed. There are now reports of the successful use of LE to treat toxicity due to these agents 13,14 . The aim of this study was to evaluate the hemodynamic changes after intravenous bupivacaine injection as a clinical scenario of toxicity and treatment with a Table 1 shows mean and standard deviations of weight and body surface areas.…”

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

“…It is not surprising that regional anaesthesia was employed in these patients. [20][21][22] Mechanisms of lipid rescue Two theories, namely the lipid sink and lipid flux theories, dominate the current understanding of the mechanisms of lipid rescue.…”

“…Because of the rarity and severity of local anaesthetic-induced cardiotoxicity, it is not possible or ethical to conduct human research on the underlying problem. 36 Human case reports 11,19,20,[37][38][39][40][41][42][43][44][45] describing successful lipid rescue are therefore invaluable. 26 When should lipid therapy be started?…”

“…46 As confidence with this therapeutic modality grows, case reports indicate progressively earlier administration of lipid emulsion during resuscitation. [19][20][21][22]37,38 This has led Weinberg to retract his earlier conservative recommendation "that lipid infusion be delayed until standard resuscitative measures failed". 10,23,46,47 What are the implications of earlier institution of lipid therapy in the presence of local anaesthetic toxicity?…”