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Neurological syndrome with acute dysesthesia and confusion during epidural anesthesia for a caesarian section. Blood concentrations of local anesthetics were considered non-toxic - 07/05/15

Doi : 10.1016/j.toxac.2015.03.071 
A. Coquerel 1, 2, 4, , M. Loilier 1, F. Girard 3, J. Bourgine 1, 4, M. Sassier 2, S. Fedrizzi 2, J. Alexandre 2, 5
1 Laboratory of Pharmacology-Toxicology 
2 Pharmacovigilance Regional Center 
3 Department of Anesthesia, University Hospital, Caen 
4 Inserm U1075, University of Caen 
5 Cardiologic Research Team EA4650, University of Caen 

Corresponding author.

Résumé

Introduction

Overdoses of local anesthetics (LA) are well-known to induce neurological or cardiologic symptoms such as convulsions, confusion, cardiac arrhythmia and cardiac failure. In most cases, LA diffuse out of a catheter used for loco-regional administration into the bloodstream. Severe side effets are observed when blood concentrations reach toxic levels. We report a case of neurological syndrome after epidural administration of lidocaine and ropivacaine at usual doses for a caesarian section. The symptoms fortunately resolved. A few minutes after the beginning of the incident, a blood sample was taken to assay the LA levels.

Case

The patient was a 37-year-old woman, primipara, with a history of Crohn's disease and endometriosis. The pregnancy was normal, bit the decision to perform a ceasarian section was made after an episode of fetal bradycardia. Regional anesthesia on D1 at 5:45 pm, with epidural LA: ropivacaine 0.2%, 10mL and lidocaine 2%, 15mL. The procedure took place normally without evidence of extravasation. The child was born with normal behavior (Apgar score 10/10 at 1 and 5min). after the birth, the mother complained of dysarthria, dusfunction of taste and labial dysesthesia. The, she exhibited dizziness and e few upper limb clonic seizures, immediately followed by relative agitation without loss of consciousness. A blood sanple was taken just before the injection of Intralipid® (soybena oil) and analyzed by GC-MS.

Results

Serum lidocaine concentration was 1.5mg/L and ropivacaine 0.10mg/L. The lidocaine concentration range considered as non-toxic in cardiology is 1.5–6mg/L. Intralipid® perfusion accelerated the rapid regression of symptoms. No other cardiac or vascular sign was reported. An MRI was done, which was normal and ruled out a stroke.

Discussion

The elimination half-life (T1/2e) of lidocaine (α=0.5h; ß=1–2h) and ropivacaine (1.8h) could not explain higher blood concentrations at the time of surgery. Reported toxic blood concentrations for lidocaine are>6mg/L. Unfortunately, we did not assay the LA-fractions. There was non-associated medication, including sedatives, morphinomimetics, antibiotics and NSAIDS that could have increased the LA-free fraction after IV injection. Other authors found various cases of LA side effects with the usual dosage and in the absence of extravasation [1]. The LA levels were also within the therapeutic range [2].

Conclusion

The acute neurological side effects induced by LA could occur at the therapeutic dosage, with blood concentrations within the usual therapeutic values.

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© 2015  Publié par Elsevier Masson SAS.
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Vol 27 - N° 2S

P. S48 - juin 2015 Retour au numéro
Article précédent Article précédent
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