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


METHODS
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 administered iv accidentally (a mixture of bupivacaine 75 mg, 15 micro g clonidine). The patient developed nodal rhythm with extreme bradycardia, severe shock and convulsions. Seizures were controlled with thiopentone/succinylcholine. Epinephrine iv boluses (0.1 mg x 3) restored blood pressure (BP) to 50/30 mmHg and heart rate (HR) to 60 (nodal rhythm). Following 75 micro g clonidine iv, BP rose to 90/70 and HR to 90 min. Cardiac rhythm reverted to sinus rhythm with first degree atrio-ventricular 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.
Favier
Jean-Christophe
JC
Intensive Care Unit, Hôpital Legouest, Metz Armées, France. legouest.daru@dial.oleane.com
Da Conceiçao
Manuel
M
Fassassi
Mikaïla
M
Allanic
Laurent
L
Steiner
Thierry
T
Pitti
Raphaël
R
D000316:Adrenergic alpha-Agonists / Q000627:therapeutic use*; D000318:Adrenergic beta-Agonists / Q000627:therapeutic use*; D000779:Anesthetics, Local / Q000009:adverse effects*; D002045:Bupivacaine / Q000009:adverse effects*; D003000:Clonidine / Q000627:therapeutic use*; D004280:Dobutamine / Q000627:therapeutic use*; D005260:Female; D006333:Heart Failure / Q000150:complications*; D006801:Humans; D007275:Injections, Intravenous / Q000009:adverse effects; D008875:Middle Aged; D012151:Resuscitation
D000316:Adrenergic alpha-Agonists; D000318:Adrenergic beta-Agonists; D000779:Anesthetics, Local; D004280:Dobutamine; D003000:Clonidine; D002045:Bupivacaine