title: Fatality involving complications of bupivacaine toxicity and hypersensitivity reaction.
abstract: This case represents unusual findings of elevated bupivacaine and tryptase concentrations following local anesthetic, bupivacaine, administered as a scalene nerve block for elective rotator cuff repair surgery. Following bupivacaine injection, the patient exhibited almost immediate seizure activity, bradycardia, and cardiac arrest. Resuscitative efforts including cardiopulmonary bypass restored a cardiac rhythm. However, the clinical medical status of the patient progressively declined and he died 7 h following administration of the local anesthetic. Autopsy revealed several abnormalities of the heart including cardiomegaly, myocardial bridging, and lipomatous hypertrophy of the intraatrial septum, which may have contributed to bradycardia and arrhythmia. Postmortem toxicology results revealed elevated bupivacaine and tryptase concentrations. Elevated postmortem bupivacaine concentrations 7 h following administration and abrupt onset of seizures indicate unintentional intravascular injection instead of nerve and tissue infiltration. An elevated postmortem tryptase concentration points to the possibility of a hypersensitivity reaction to bupivacaine.
authors.affiliation: Office of Jackson County Medical Examiner, 660 East 24th Street, Kansas City, MO 64108, USA. mdudley@jacksongov.org
authors.forename: Mary H
authors.initials: MH
authors.lastname: Dudley
authors.forename: Steven W
authors.initials: SW
authors.lastname: Fleming
authors.forename: Uttam
authors.initials: U
authors.lastname: Garg
authors.forename: Jason M
authors.initials: JM
authors.lastname: Edwards
mesh_terms: D000328:Adult; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000009:adverse effects*; D054087:Atrial Septum / Q000473:pathology; D001919:Bradycardia / Q000139:chemically induced; D002045:Bupivacaine / Q000008:administration & dosage / Q000009:adverse effects*; D006332:Cardiomegaly / Q000473:pathology; D004342:Drug Hypersensitivity / Q000209:etiology*; D053593:Forensic Toxicology; D006323:Heart Arrest / Q000139:chemically induced*; D006801:Humans; D006984:Hypertrophy; D008297:Male; D009206:Myocardium / Q000473:pathology; D009407:Nerve Block / Q000009:adverse effects / Q000379:methods; D012640:Seizures / Q000139:chemically induced; D053802:Tryptases / Q000097:blood
chemical_list: D000779:Anesthetics, Local; D053802:Tryptases; D002045:Bupivacaine