title: Central nervous system toxicity following the administration of levobupivacaine for lumbar plexus block: A report of two cases.
abstract: OBJECTIVE
  Central nervous system and cardiac toxicity following the administration of local anesthetics is a recognized complication of regional anesthesia. Levobupivacaine, the pure S(-) enantiomer of bupivacaine, was developed to improve the cardiac safety profile of bupivacaine. We describe 2 cases of grand mal seizures following accidental intravascular injection of levobupivacaine.
  
  
  METHODS
  Two patients presenting for elective orthopedic surgery of the lower limb underwent blockade of the lumbar plexus via the posterior approach. Immediately after the administration of levobupivacaine 0.5% with epinephrine 2.5 microgram/mL, the patients developed grand mal seizures, despite negative aspiration for blood and no clinical signs of intravenous epinephrine administration. The seizures were successfully treated with sodium thiopental in addition to succinylcholine in 1 patient. Neither patient developed signs of cardiovascular toxicity. Both patients were treated preoperatively with beta-adrenergic antagonist medications, which may have masked the cardiovascular signs of the unintentional intravascular administration of levobupivacaine with epinephrine.
  
  
  CONCLUSIONS
  Although levobupivacaine may have a safer cardiac toxicity profile than racemic bupivacaine, if adequate amounts of levobupivacaine reach the circulation, it will result in convulsions. Plasma concentrations sufficient to result in central nervous system toxicity did not produce manifestations of cardiac toxicity in these 2 patients.
authors.affiliation: Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA. bres1002@mc.duke.edu
authors.forename: Dara S
authors.initials: DS
authors.lastname: Breslin
authors.forename: Gavin
authors.initials: G
authors.lastname: Martin
authors.forename: David B
authors.initials: DB
authors.lastname: Macleod
authors.forename: Francine
authors.initials: F
authors.lastname: D'ercole
authors.forename: Stuart A
authors.initials: SA
authors.lastname: Grant
mesh_terms: D000368:Aged; D000779:Anesthetics, Local / Q000009:adverse effects*; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D002045:Bupivacaine / Q000009:adverse effects*; D002493:Central Nervous System Diseases / Q000139:chemically induced*; D004830:Epilepsy, Tonic-Clonic / Q000139:chemically induced; D004837:Epinephrine / Q000494:pharmacology; D005260:Female; D006801:Humans; D008160:Lumbosacral Plexus; D008297:Male; D009407:Nerve Block / Q000009:adverse effects*; D020258:Neurotoxicity Syndromes / Q000503:physiopathology*; D014662:Vasoconstrictor Agents / Q000494:pharmacology
chemical_list: D000779:Anesthetics, Local; D014662:Vasoconstrictor Agents; D002045:Bupivacaine; D004837:Epinephrine