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

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.