Successful defibrillation immediately after the intravascular injection of ropivacaine

Abstract

P Pu ur rp po os se e: : To report successful resuscitation of ventricular fibrillation induced by accidental intravascular injection of ropivacaine.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : A 15-yr-old healthy girl weighing 59 kg was scheduled for transposition of the tibial tuberosity under combined sciatic/three-in-one block. No premedication was given. In the induction room, an iv infusion was started, along with electrocardiogram monitoring, non-invasive blood-pressure measurement and pulse-oximetry. The sciatic nerve was found with the use of a nerve stimulator at the first attempt by the classical approach of Labat. Aspiration for blood was negative and the injection of ropivacaine 0.75% without epinephrine started. Convulsions, followed within seconds by ventricular fibrillation occurred at the end of the injection of 18 mL ropivacaine 0.75%. Oxygen was administered by face mask ventilation and immediate defibrillation was successful on the second attempt (2 × 200 joules). Within two minutes convulsions stopped and normal cardiac rhythm returned. Propofol and sufentanil were injected and a laryngeal mask inserted to start general anesthesia for surgery. Postoperatively no evidence of sciatic block could be demonstrated. The patient did not remember the event and was discharged the following day with no residual effects.

Ropivacaine cardiac toxicity — not as troublesome as bupivacaine

“…[4][5][6] In this issue of the Canadian Journal of Anesthesia there is an additional report of ventricular fibrillation following an accidental intravascular injection of ropivacaine. 7 There were some interesting aspects about this case that are worthy of comment. This case clearly illustrates the importance of monitoring patients when injecting potent local anesthetics.…”

“…It is interesting to note that single injection, epidural techniques were frequently used by anesthesiologists in obstetric patients presenting for Cesarean section 25 years ago when Albright alerted us about bupivacaine cardiac toxicity. 7 There seems to be some confusion among anesthesiologists about what constitutes a safe dose of ropivacaine. Most anesthesiologists select the dose of local anesthetic based upon the weight of the patient.…”

“…There is no correlation between the weight of patients and the plasma concentration achieved after a given dose (mg·kg -1 ) of local anesthetic. 7 The Compendium of Pharmaceuticals and Specialties recommends a maximum dose of 300 mg of ropivacaine for major nerve blocks such as brachial plexus using a 0.75% concentration in adults. 8 It is wise to adhere to these dosage recommendations when using potent local anesthetic agents such as bupivacaine and ropivacaine.…”

“…[4][5][6] Dans le présent numéro du Journal, un nouvel article rapporte de la fibrillation ventriculaire suivant l'injection intravasculaire accidentelle de ropivacaïne. 7 Certains aspects intéressants de ce cas méritent d'être commentés. Ils illustrent clairement l'importance du monitorage avec l'usage d'anesthésiques locaux puissants.…”

“…Fait à noter, des techniques péridurales d'injection unique ont été fréquemment utilisées par les anesthésiologistes en obstétrique pour la césarienne il y a 25 ans, au moment où Albright a attiré l'attention sur la toxicité cardiaque liée à la bupivacaïne. 7 Il semble y avoir une certaine confusion parmi les anesthésiologistes sur ce qu'est une dose sûre de ropivacaïne. La plupart vont choisir la dose d'anesthésique local d'après le poids du patient.…”