Journal of Anesthesia

, 25:442 | Cite as

Successful treatment of ropivacaine-induced central nervous system toxicity by use of lipid emulsion: effect on total and unbound plasma fractions

Clinical Report

Abstract

A 24-year-old man underwent surgery for a fractured left clavicle and received an interscalene brachial plexus block for intraoperative and postoperative analgesia. After injection of 40 ml 0.5% ropivacaine and confirmation of analgesia, general anesthesia was induced and maintained with propofol. Although the operation was completed uneventfully, the patient was restless and there was limb twitching during emergence from anesthesia. Ropivacaine-induced toxicity was suspected, and a dose of 100 ml 20% lipid emulsion was infused intravenously. The symptoms of toxicity disappeared, and there was full recovery of consciousness within 5 min. Plasma concentrations of total and protein-unbound ropivacaine measured 2 h 20 min after local injection were 1.99 and 0.13 μg/ml, respectively. After infusion of lipid emulsion, the ropivacaine concentrations decreased to 1.72 and 0.05 μg/ml, respectively. The patient had no pain, and neurological examination revealed sensory loss around the clavicle. The patient was discharged without any complications.

Keywords

Local anesthetic Ropivacaine Toxicity Peripheral nerve block Lipid emulsion 

References

  1. 1.
    Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB. Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology. 2006;105:217–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Ludot H, Tharin JY, Belouadah M, Mazoit JX, Malinovsky JM. Successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesth Analg. 2008;106:1572–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Litz RJ, Roessel T, Heller AR, Stehr SN. Reversal of central nervous system and cardiac toxicity after local anesthetic intoxication by lipid emulsion injection. Anesth Analg. 2008;106:1575–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Spence AG. Lipid reversal of central nervous system symptoms of bupivacaine toxicity. Anesthesiology. 2007;107:516–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Charbonneau H, Marcou TA, Mazoit JX, Zetlaoui PJ, Benhamou D. Early use of lipid emulsion to treat incipient mepivacaine intoxication. Reg Anesth Pain Med. 2009;34:277–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Calenda E, Dinescu SA. Failure of lipid emulsion to reverse neurotoxicity after an ultrasound-guided axillary block with ropivacaine and mepivacaine. J Anesth. 2009;23:472–3.PubMedCrossRefGoogle Scholar
  7. 7.
    Neal JM, Bernards CM, Butterworth JF 4th, Di Gregorio G, Drasner K, Hejtmanek MR, Mulroy MF, Rosenquist RW, Weinberg GL. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35:152–61.PubMedCrossRefGoogle Scholar
  8. 8.
    Mazoit JX, Le Guen R, Beloeil H, Benhamou D. Binding of long-lasting local anesthetics to lipid emulsions. Anesthesiology. 2009;110:380–6.PubMedGoogle Scholar
  9. 9.
    Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-Amaro MF, Cwik MJ. Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats. Anesthesiology. 1998;88:1071–5.PubMedCrossRefGoogle Scholar
  10. 10.
    Nakamura T, Oda Y, Takahashi R, Tanaka K, Hase I, Asada A. Propranolol increases the threshold for lidocaine-induced convulsions in awake rats: a direct effect on the brain. Anesth Analg. 2008;106:1450–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Knudsen K, Beckman Suurküla M, Blomberg S, Sjövall J, Edvardsson N. Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. Br J Anaesth. 1997;78:507–14.PubMedGoogle Scholar
  12. 12.
    Ikeda Y, Oda Y, Nakamura T, Takahashi R, Miyake W, Hase I, Asada A. Pharmacokinetics of lidocaine, bupivacaine, and levobupivacaine in plasma and brain in awake rats. Anesthesiology. 2010;112:1396–403.PubMedCrossRefGoogle Scholar
  13. 13.
    Takahashi R, Oda Y, Tanaka K, Morishima HO, Inoue K, Asada A. Epinephrine increases the extracellular lidocaine concentration in the brain: a possible mechanism for increased central nervous system toxicity. Anesthesiology. 2006;105:984–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Wank W, Büttner J, Maier KR, Emanuelson BM, Selander D. Pharmacokinetics and efficacy of 40 ml ropivacaine 7.5 mg/ml (300 mg), for axillary brachial plexus block––an open pilot study. Eur J Drug Metab Pharmacokinet. 2002;27:53–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Borgeat A, Ekatodramis G, Blumenthal S. Interscalene brachial plexus anesthesia with ropivacaine 5 mg/mL and bupivacaine 5 mg/mL: effects on electrocardiogram. Reg Anesth Pain Med. 2004;29:557–63.PubMedGoogle Scholar
  16. 16.
    Emanuelsson BM, Persson J, Sandin S, Alm C, Gustafsson LL. Intraindividual and interindividual variability in the disposition of the local anesthetic ropivacaine in healthy subjects. Ther Drug Monit. 1997;19:126–31.PubMedCrossRefGoogle Scholar
  17. 17.
    Maurer K, Ekatodramis G, Rentsch K, Borgeat A. Interscalene and infraclavicular block for bilateral distal radius fracture. Anesth Analg. 2002;94:450–2.PubMedGoogle Scholar
  18. 18.
    Hickey R, Blanchard J, Hoffman J, Sjovall J, Ramamurthy S. Plasma concentrations of ropivacaine given with or without epinephrine for brachial plexus block. Can J Anaesth. 1990;37:878–82.PubMedCrossRefGoogle Scholar
  19. 19.
    Vainionpää VA, Haavisto ET, Huha TM, Korpi KJ, Nuutinen LS, Hollmén AI, Jozwiak HM, Magnusson AA. A clinical and pharmacokinetic comparison of ropivacaine and bupivacaine in axillary plexus block. Anesth Analg. 1995;81:534–8.PubMedGoogle Scholar
  20. 20.
    Hartung J, Ying H, Weinberger J, Cottrell JE. Propofol prevents or elevates the threshold for lidocaine-induced seizures in rats. J Neurosurg Anesthesiol. 1994;6:254–9.PubMedGoogle Scholar
  21. 21.
    Sirianni AJ, Osterhoudt KC, Calello DP, Muller AA, Waterhouse MR, Goodkin MB, Weinberg GL, Henretig FM. Use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Ann Emerg Med. 2008;51:412–5.PubMedCrossRefGoogle Scholar
  22. 22.
    de Jong RH. Lipid infusion for cardiotoxicity: promise? Yes-panacea? Not. Anesthesiology. 2007;106:635–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Brull SJ. Lipid emulsion for the treatment of local anesthetic toxicity: patient safety implications. Anesth Analg. 2008;106:1337–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Weinberg G. Lipid infusion therapy: translation to clinical practice. Anesth Analg. 2008;106:1340–2.PubMedCrossRefGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2011

Authors and Affiliations

  1. 1.Department of Anesthesia and Operating TheaterOsaka Kaisei HospitalOsakaJapan
  2. 2.Department of AnesthesiologyOsaka City University Graduate School of MedicineOsakaJapan
  3. 3.Division of Intensive Care UnitHyogo College of MedicineNishinomiyaJapan

Personalised recommendations