Abstract Text:
Regional Anaesthesia
1153
Local Anaesthetic Toxicity Due To The Migration
Of An Epidural Catheter: A Rare Complication
Due To a Rare Situation
Toxicity,local anaesthetics, Anaesthetic techniques,regional, Heart,resuscitation
M. Rodriguez1, I. Hinojal Blanco1, M. GarcíA áLvarez1, F. J. GonzáLez Carrasco1, M. Victoria1
1Hospital De la Santa Creu i Sant Pau - Barcelona (Spain)

BACKGROUND
Local anaesthetics can cross cell membranes and interact with charged targets and signaling systems. For that reason, they produce a variety of toxic effects in several tissue types: heart, brain and skeletal muscle. Systemic toxicity occurs in 1:10,000 for epidurals, but this data is not clear due to the low incidence. Infusion of 20% lipid emulsion to treat severe systemic drug toxicity is the election treatment in this situation.

CASE REPORT
24 year old parturient woman, with no diseases and no allergies. She asked for epidural analgesia. Technique was performed in one attempt, with no incidences. Epidural space was at 5 cm from the skin, so catheter was placed at 10 cm and bupivacaine infusion was started. During the first 4 hours, no incidences appeared, and correct analgesia was achieved. After that, the anaesthesiologist was called due to patient’s pain. Before administering using the placed catheter, syringe aspiration obtained blood. After reviewing the catheter position, it was noticed that it was placed at 13 cm, 3 more inside than before. While these manoeuvres were being performed, the patient presented metallic taste, dizziness, visual and auditory disturbances, with disorientation and drowsiness. At that moment bupivacaine infusion was stopped, and monitoring and lipid 20% infusion were started. At the same time, the anaesthesiologist asked for help, and prepared the drugs needed in case of cardiac arrest. After 5 minutes, the patient recovered ad integrum. Toxic doses of local anaesthetic were not reached.
DISCUSSION
Even though the catheter was initially correctly placed, it seems that vascular migration is the cause of the toxicity, even though we have not found any described case in the literature. Lipid Rescue seems to be an effective treatment, according to our experience and the several case reports found after our review. More data is needed: the current knowledge is only about reports of cases, due to the low incidence of this entity.

LEARNING POINTS
- Local Anaesthetic toxicity is a rare condition that can be devastating.
- Due to the low incidence, reporting the cases is essential to learn about how to treat it.
- Intravascular infusion of local anaesthetic, especially bupivacaine, is a potentially dangerous cause of toxicity.
- Once the diagnosis is suspected, lipid rescue must be started: the consequences (including cardiac arrest) can be fatal. This includes asking for help.

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