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.
Educational Objectives
- •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 http://www.assh.org/professionals/jhs.
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 accessOne-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:
Subscribe to Journal of Hand SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Essentials of pain medicine and regional anesthesia.in: 2nd ed. Elsevier, Philadelphia2005: 632
- The incidence of neurovascular complications following axillary brachial plexus block using a transarterial approach.Reg Anesth Pain Med. 1995; 20: 486-492
- Ultrasound guidance for axillary plexus block does not prevent intravascular injection.Anesthesiology. 2008; 108: 761
- Intravascular injection during ultrasound-guided axillary block: negative aspiration can be misleading.Int Anesth Res Soc. 2008; 107: 1754-1755
- Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats.Anesthesiology. 1998; 88: 1071-1075
- Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity.Reg Anesth Pain Med. 2003; 28: 198-202
- Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest.Anesthesiology. 2006; 105: 217-218
- Lipid infusion resuscitation for local anesthetic toxicity: proof of clinical efficacy.Anesthesiology. 2006; 105: 7-8
- Guidelines for the management of severe local anesthetic toxicity, 2007.(Accessed July 23, 2008)
- Lipid rescue resuscitation from local anesthetic cardiac toxicity.Toxicol Rev. 2006; 25: 139-145
- Lipid, not propofol, treats bupivacaine overdose.Anesth Analg. 2004; 99: 1875-1876
- Lipid rescue: caveats and recommendations for the “silver bullet.”.Reg Anesth Pain Med. 2004; 29: 74-75
- Recurrence of cardiotoxicity after lipid rescue from bupivacaine-induced cardiac arrest.Int Anesth Res Soc. 2009; 108: 1344-1346
Article info
Publication history
Accepted:
October 19,
2009
Received:
October 19,
2009
Footnotes
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Identification
Copyright
© 2010 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Journal CME QuestionsJournal of Hand SurgeryVol. 35Issue 1
