In brief| Volume 35, ISSUE 1, P144-146, January 2010

Lipid Infusion Rescue for Bupivacaine-Induced Cardiac Arrest After Axillary Block

      Bupivacaine, a long-acting local anesthetic agent, is widely used for pain control in ambulatory surgery patients. Surgeons and anesthesiologists employ bupivacaine for cutaneous infiltration, intra-articular injection, peripheral nerve blocks, epidural anesthesia, and spinal anesthesia. Unlike lidocaine, bupivacaine is highly lipophilic. Accidental bupivacaine intravascular injection or excessive systemic absorption can lead to cardiac depression, severe arrhythmias, hypotension, and/or cardiac arrest. Resuscitation of patients with bupivacaine toxicity may be difficult, prolonged, and, in some cases, impossible. Heroic measures including cardiopulmonary bypass have been performed in cases in which conventional resuscitative measures failed. Lipid emulsion has recently been advocated as a new therapy to treat bupivacaine systemic toxicity. This article reports the successful resuscitation of a hand surgery patient after inadvertent intravascular injection of bupivacaine during axillary block and reviews the pertinent literature.
      • Describe lipid emulsion therapy.
      • List the indications for lipid emulsion therapy.
      • State the mechanism of action for lipid emulsion therapy.
      • Discuss the techniques to decrease the possibility of intravascular injection during axillary block.
      Earn up to 2 hours of CME credit per JHS issue when you read the related articles and take the online test. To pay the $20 fee and take this month's test, visit
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Benzon H.
        • Raja S.
        • Molloy R.
        • Liu
        • Fishman S.
        Essentials of pain medicine and regional anesthesia.
        in: 2nd ed. Elsevier, Philadelphia2005: 632
        • Stan T.
        • Krantz M.
        • Solomon D.
        • Poulos J.
        • Chaoukik K.
        The incidence of neurovascular complications following axillary brachial plexus block using a transarterial approach.
        Reg Anesth Pain Med. 1995; 20: 486-492
        • Zetlaoui P.
        • Labbe J.
        • Benhamon D.
        Ultrasound guidance for axillary plexus block does not prevent intravascular injection.
        Anesthesiology. 2008; 108: 761
        • Robards C.
        • Clendensen S.
        • Greengrass R.
        Intravascular injection during ultrasound-guided axillary block: negative aspiration can be misleading.
        Int Anesth Res Soc. 2008; 107: 1754-1755
        • Weinberg G.
        • VadeBoncouer T.
        • Ramaraju G.A.
        • Garcia-Amaro M.F.
        • Cwik M.
        Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats.
        Anesthesiology. 1998; 88: 1071-1075
        • Weinberg G.
        • Ripper R.
        • Feinstein D.L.
        • Hoffman W.
        Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity.
        Reg Anesth Pain Med. 2003; 28: 198-202
        • Rosenblatt M.A.
        • Abel M.
        • Fischer G.W.
        • Itzkovich C.J.
        • Eisenkraft J.B.
        Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest.
        Anesthesiology. 2006; 105: 217-218
        • Weinberg G.
        Lipid infusion resuscitation for local anesthetic toxicity: proof of clinical efficacy.
        Anesthesiology. 2006; 105: 7-8
        • The Association of Anaesthetists of Great Britain and Ireland
        Guidelines for the management of severe local anesthetic toxicity, 2007.
        (Accessed July 23, 2008)
        • Weinberg G.
        Lipid rescue resuscitation from local anesthetic cardiac toxicity.
        Toxicol Rev. 2006; 25: 139-145
        • Weinberg G.
        • Hentz P.
        Lipid, not propofol, treats bupivacaine overdose.
        Anesth Analg. 2004; 99: 1875-1876
        • Weinberg G.
        Lipid rescue: caveats and recommendations for the “silver bullet.”.
        Reg Anesth Pain Med. 2004; 29: 74-75
        • Marwick P.C.
        • Levin A.I.
        • Coetzee A.R.
        Recurrence of cardiotoxicity after lipid rescue from bupivacaine-induced cardiac arrest.
        Int Anesth Res Soc. 2009; 108: 1344-1346

      Linked Article