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Year : 2015  |  Volume : 8  |  Issue : 6  |  Page : 807-809  

Successful lipid rescue of local anesthetic systemic toxicity following peribulbar block

1 Department of Anaesthesia and Pain Medicine, MS Ramaiah Medical College and Hospitals, Bengaluru, Karnataka, India
2 Department of Ophthalmology, MS Ramaiah Medical College and Hospitals, Bengaluru, Karnataka, India

Date of Web Publication19-Nov-2015

Correspondence Address:
Vinayak S Pujari
Department of Anaesthesia and Pain Medicine, MS Ramaiah Medical College and Hospitals, New BEL Road, MSR Nagar, Bengaluru - 560 054, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-2870.169942

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Local anesthesia is commonly used to perform cataract surgery. We present a case in which local anesthesia systemic toxicity, which occurred after peribulbar block. It is a life-threatening complication if it is not recognized early and appropriately resuscitated can be fatal. This case report attempts to highlight the need for trained personnel, with suitable monitoring and recent guidelines in the management of local anesthesia systemic toxicity surgery under a regional technique.

Keywords: Anesthesia, anesthetic techniques, complications, local anesthetic toxicity, ophthalmological, regional

How to cite this article:
Pujari VS, Bhandary AS, Bevinaguddaiah Y, Shivanna S. Successful lipid rescue of local anesthetic systemic toxicity following peribulbar block. Med J DY Patil Univ 2015;8:807-9

How to cite this URL:
Pujari VS, Bhandary AS, Bevinaguddaiah Y, Shivanna S. Successful lipid rescue of local anesthetic systemic toxicity following peribulbar block. Med J DY Patil Univ [serial online] 2015 [cited 2020 Dec 6];8:807-9. Available from:

  Introduction Top

In patients undergoing ophthalmic surgery under regional anesthesia, major complications are rare. [1] Local anesthetic systemic toxicity (LAST) is a known complication of regional anesthesia. There are only few reports of LAST in ophthalmic setting. [2],[3] We describe the first case of successful resuscitation with lipid emulsion infusion for local anesthetic-induced central nervous system and cardiovascular toxicity after peribulbar block.

  Case Report Top

A 55-year-old, 68 kg male was scheduled for cataract surgery and lens implant for his right eye. He was a hypertensive on oral amlodipine 5 mg OD, no history of any other medical illness, drug allergies or previous surgeries. His preoperative investigations and electrocardiogram (ECG) was normal.

He was allowed a light breakfast and antihypertensive medication were continued on the morning of surgery. His systemic examination was unremarkable, the blood pressure which was 136/82 mmHg on the morning of surgery. After ensuring asepsis and that the eye was in the primary gaze position, a 24 G 25 mm needle was introduced through the skin of the lower lid sulcus at the inferolateral angle of the orbit. The needle was inserted along the orbital wall to a depth of 2 cm. After negative aspiration, a mixture bupivacaine 25 mg, lidocaine 100 mg and hyaluronidase 500 IU mixture (10 ml volume) was injected by an ophthalmology resident. The patient had a grand-mal seizure within a minute after injection.

The anesthesiologists help from the adjacent theatre saw sought, injection midazolam 1.5 mg intravenous (i.v) was administered after securing an 18G i.v line on the dorsum of the hand. Simultaneously the patient was mask ventilated with 100% oxygen, and a multi-parameter monitor was connected. The ECG showed a heart rate of 130 beats/min with multiple supraventricular ectopic beats, blood pressure of 180/104 mm Hg and oxygen saturation of 98%.The patient had no further seizures, but he was disoriented and responsive to only painful stimulus. He was regularly breathing with good tidal volume. Pupillary reaction could not be assessed due to the dilatation. A random blood sugar showed 136 mg/dl.

A probable diagnosis of LAST was done in view of seizures and cardiovascular instability following a local anesthetic administration. To prevent further deterioration of the patient the decision to initiate lipid emulsion therapy was taken. 100 ml bolus of lipid emulsion (Intralipid 20%, Fresenius Kabi, Bad Homburg, Germany) over 1 min followed by 600 ml over 30 min was infused. The patient regained full consciousness and was oriented 5 min after the initial bolus of lipid. ECG reverted to normal sinus rhythm 10 min after initiating the infusion. The surgery was deferred and the patient was shifted to the intensive care unit, the patient was discharged after monitoring for 8 h as 12 lead ECG showed no fresh changes and other investigations were normal.

  Discussion Top

Peribulbar block produces optimal conditions for the performance of eye surgery. Davis and Mandel found only 1 major complication (0.006%), a grand-mal seizure that might have been related to systemic toxicity in 16,224 patients who received a peribulbar block. [1] The inferior ophthalmic artery may be prone to injury as it has an anomalous position, inferior to the optic nerve in 15% of cases. [2] Inadvertent intra-arterial injection may reverse blood flow in the ophthalmic artery up to the anterior cerebral or the internal carotid artery, an injected volume as small as 4 ml can produce seizures. [4] LAST can range from excitement, perioral tingling and numbness to seizures and cardiovascular collapse depending on the dose and the local anesthetic used. [5] In our case, the probable direct intravascular injection resulted in LAST, as the seizures were triggered immediately after the block.

We could rule out brain stem anesthesia as the patient did not exhibit the classical signs such as apnea, hemiplegia, paraplegia, quadriplegia, or hyperreflexia or blockade of the eighth to twelfth cranial nerves, which could result in deafness, vertigo, vagolysis, dysphagia, aphasia, and loss of neck muscle power. [6],[7] In addition, a retrobulbar block is more likely to be associated with brain stem anesthesia due to the use of a longer needle.

The accepted approach in the management of LAST is securing the airway as the initial priority to assure optimal oxygenation and ventilation; subsequently seizure suppression, preferably with a short-acting benzodiazepine-like midazolam; finally, lipid emulsion infusion to reverse the manifestations of LAST [Table 1]. When clinically indicated basic life support including chest compressions must be used in order to circulate resuscitation drugs, including lipid and to assure tissue perfusion. In our patient, the amount of local anesthetic used was small approximately 10 ml, but in view of the CNS and cardiac manifestation the decision to use lipid emulsion was undertaken to preempt further worsening of the patient.
Table 1: Treatment of local anesthetic toxicity

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The proposed mechanism of action is that the emulsion forms a lipid sink that traps the molecule in a lipid partition of the plasma, preventing molecule-effector interaction and subsequent downstream effects. Also, a metabolic theory is that a large lipid load could offset the potent inhibition of fatty acid metabolism caused by bupivacaine. [9] The American Society of Regional Anesthesia (ASRA), Association of Anesthetists of Great Britain and Ireland and the American Heart Association, have come out with guidelines for the use of lipid emulsion in LAST. [9] The ASRA Practice Advisory on LAST recommends administering lipid emulsion at the first signs of LAST. The ASRA guideline requires a large initial i.v bolus of 20% lipid emulsion (approximately 1.5 ml/kg of lean body mass) that is followed by a continuous infusion (approximately 0.25 ml/kg/min) for about 10 min following recovery of vital signs. [8] There are multiple case reports of lipid emulsion being used successfully to treat LAST and other drug toxicities. [9],[10]

Simple measures such as repeated aspiration, use of incremental doses of local anesthetics or use of test dose can prevent LAST. An i.v access, oxygen supplementation and continuous monitoring of vitals are mandatory for patients undergoing surgery even under local anesthesia. These simple measures are not followed in centers with large case volumes like ours and were a disaster in the making. This case was an eye opener for the ophthalmology department, following which siting an i.v cannula and institution of monitoring has become mandatory before starting the case under local anesthesia. Improved physician alertness, education and optimized treatment protocols, will reduce the rate of morbidity and mortality from LAST. A recent simulation workshop on LAST conducted by the anesthesia department helped in the early diagnosis and successful management of this case. We now have intralipid in the theatre complex, which is readily available for the treatment of LAST [Figure 1]. In conclusion, we could successfully manage the case due to timely recognition of LAST and further deterioration was prevented by early intervention with Lipid emulsion.
Figure 1: Lipid emulsion box readily available in the theatre for
treatment of local anesthetic systemic toxicity

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  References Top

Davis DB 2 nd , Mandel MR. Efficacy and complication rate of 16,224 consecutive peribulbar blocks. A prospective multicenter study. J Cataract Refract Surg 1994;20:327-37.  Back to cited text no. 1
Meyers EF, Ramirez RC, Boniuk I. Grand mal seizures after retrobulbar block. Arch Ophthalmol 1978;96:847.  Back to cited text no. 2
Rozentsveig V, Yagev R, Wecksler N, Gurman G, Lifshitz T. Respiratory arrest and convulsions after peribulbar anesthesia. J Cataract Refract Surg 2001;27:960-2.  Back to cited text no. 3
Aldrete JA, Romo-Salas F, Arora S, Wilson R, Rutherford R. Reverse arterial blood flow as a pathway for central nervous system toxic responses following injection of local anesthetics. Anesth Analg 1978;57:428-33.  Back to cited text no. 4
Berde CB, Strichartz GR. Local anesthetics. In: Miller RD, Eriksson LI, Fleisher LA, Weiner-Koronish JP, Young WL, editors. Miller's Anesthesia. 7 th ed. USA: Elsevier; 2010. p 913-39.  Back to cited text no. 5
Hamilton RC. Brain stem anesthesia following retrobulbar blockade. Anesthesiology 1985;63:688-90.  Back to cited text no. 6
Gunja N, Varshney K. Brainstem anaesthesia after retrobulbar block: A rare cause of coma presenting to the emergency department. Emerg Med Australas 2006;18:83-5.  Back to cited text no. 7
Neal JM, Bernards CM, Butterworth JF 4 th , Di Gregorio G, Drasner K, Hejtmanek MR, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med 2010;35:152-61.  Back to cited text no. 8
Weinberg GL. Lipid emulsion infusion: Resuscitation for local anesthetic and other drug overdose. Anesthesiology 2012;117:180-7.  Back to cited text no. 9
Rothschild L, Bern S, Oswald S, Weinberg G. Intravenous lipid emulsion in clinical toxicology. Scand J Trauma Resusc Emerg Med 2010;18:51.  Back to cited text no. 10


  [Figure 1]

  [Table 1]

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