Bupivacaine overdose requiring multiple administrations of intravenous lipid emulsion therapy: A case report

Michael L. Behal , Reba A. Hodge , Matthew C. Blackburn
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Abstract

Background

Bupivacaine, an amide local anesthetic, is commonly used in intrathecal pumps (IT) for pain and spasticity disorders. Pump malfunctions place patients at risk of bupivacaine overdose and local anesthetic systemic toxicity (LAST); however, there are limited reports of this in the literature.

Case report

A 24-year-old male with an IT bupivacaine/baclofen pump presented with weakness, numbness, dyspnea, and somnolence secondary to IT pump malfunction with an unknown amount of bupivacaine/baclofen extravasation into the subcutaneous space. The patient required intubation and vasopressor support but remained persistently hypotensive and bradycardic despite aggressive dose titration. Needle aspiration was performed to remove 14 mL of extravasated drug mixture. Due to persistent hemodynamic instability, intravenous lipid emulsion (ILE) therapy was initiated with 20 ​% lipid emulsion 1.5 mL/kg bolus followed by a continuous infusion of 0.25 mL/kg/min. The patient became hemodynamically stable following 750mL of ILE therapy and was admitted to the intensive care unit. Five hours after ILE therapy cessation, the patient again became hemodynamically unstable, and ILE was re-initiated with a bolus and continuous infusion. Sustained hemodynamic stability was achieved after an additional 450mL of ILE.

Why should an emergency physician be aware of this?

IT pump malfunction involving bupivacaine can lead to severe LAST necessitating ILE therapy. Clinicians should be aware of the potential for drug deposition leading to prolonged or recurrent hemodynamic instability requiring repeated administration of ILE therapy.

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布比卡因过量需要多次静脉脂乳治疗:一例报告
背景布比卡因是一种酰胺类局部麻醉剂,通常用于鞘内泵(IT)治疗疼痛和痉挛性疾病。泵故障使患者面临布比卡因过量和局部麻醉全身毒性(LAST)的风险;然而,文献中关于这方面的报道有限。病例报告:一名24岁的男性,布比卡因/巴氯芬泵出现虚弱、麻木、呼吸困难和嗜睡,继发于布比卡因/巴氯芬泵故障,并有未知数量的布比卡因/巴氯芬外渗到皮下间隙。患者需要插管和血管加压支持,但尽管积极剂量滴定,仍持续低血压和心动过缓。用针吸法取出14 mL外渗药物混合物。由于持续的血流动力学不稳定,静脉脂质乳(ILE)治疗开始时为20%脂质乳1.5 mL/kg,然后持续输注0.25 mL/kg/min。经750mL ILE治疗后,患者血流动力学稳定,并入住重症监护病房。停止ILE治疗5小时后,患者再次出现血流动力学不稳定,再次开始给药并持续输注ILE。在增加450mL ILE后,实现了持续的血流动力学稳定。急诊医生为什么要意识到这一点?布比卡因引起的IT泵故障可导致严重的LAST,需要ILE治疗。临床医生应该意识到药物沉积可能导致延长或复发性血流动力学不稳定,需要反复给予ILE治疗。
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来源期刊
JEM reports
JEM reports Emergency Medicine
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