Successful resuscitation of serious bupivacaine intoxication in a patient with pre-existing heart failure

Abstract

Purpose: In dogs intoxicated with bupivacaine, clonidine is effective to treat conduction disturbances and dobutamine corrects myocardial depression. We report the case of a patient who experienced severe bupivacaine cardiotoxicity and who was treated successfully using these medications. Clinical features: In a patient with pre-existing heart failure a surgical procedure to fix a humeral fracture was necessary. Preoperatively, heart failure was controlled with transcutaneous nitroglycerin and iv deslanoside. A bupivacaine bolus was administred iv accidentally (a mixture of bupivacaine 75 mg, 15 μg clonidine). The patient developped nodal rhythm with extreme bradycardia, severe shock and convulsions. Seizures were controlled with thiopentone/succinylcholine. Epinephrine iv boluses (0.1 mg × 3) restored blood pressure (BP) to 50/30 mmHg and heart rate (HR) to 60 (nodal rhythm). Following 75 μg clonidine iv, BP rose to 90/70 and HR to 90 min. Cardiac rhythm reverted to sinus rhythm with first degree atrioventricular block. Echocardiography showed hyperkinesia and relative hypovolemia that was controlled with iv administration of terlipressin and glucagon. Subsequent dobutamine infusion stabilized hemodynamic conditions. It was decided to proceed with surgery using a midazolam/sufentanil based general anesthetic. In the intensive care unit, recovery, extubation and weaning from the dobutamine infusion were realized within 16 hr of the event. Conclusions: In this patient with preoperative heart failure, clonidine was effective to treat bupivacaine induced conduction disturbances. Epinephrine and dobutamine were effective to treat myocardial depression and terlipressin effectively controlled vasodilatation.