A 4-year-old boy with 25 kg weight presented to the Emergency Department of Imam Hospital of Sari in December 2013 due to tonic-clonic generalized seizures approximately 30 min ago. 3 h before seizure, his mother mistakenly gave him 2 spoons (amount 20–25 cc) lidocaine hydrochloride 2% solution instead of pediatric gripe. Seizure with generalized tonic-clonic occurred 3 times in home. On arrival at our Emergency Department, she was agitated and had confused speech with Glasgow coma scale score of 14/15. His initial blood pressure was 90/55 mmHg with a pulse rate of 130 beats/min.\nHis temperature was 36.9°C axial. Respiratory rate was 20 per min with a SpO2 of 96% on 2 L of nasal oxygen. Twitching movement with muscle spasm was noticed in the limbs. The pupils were 4 mm in diameter, equal and reactive, and no focal neurological deficit was found. His skin was normal. Bowel sound was normal, and the bladder was not palpable. An electrocardiogram (ECG) showed sinus tachycardia with a heart rate of 139 beats/min, and QT interval was 0.89 s. Neurologic examination was essentially unremarkable except for the depressed level of consciousness. The personal and medical history was unremarkable; including the absence of birthing trauma or febrile seizures. He had no history of use of other drugs.\nLaboratory studies while the patient received supplemental oxygen included an arterial blood gas with pH 7.30; pO2104 mm Hg; pCO239 mmHg; and HCO321. A complete blood count revealed white blood cells 10,400/mm3(31% polymorphonuclear leukocytes, 64% lymphocytes, 5% monocytes); hemoglobin 12 g; and hematocrit 35%. Blood chemistry studies were unremarkable except for an elevated glucose (219 mg %) obtained while the patient was receiving an IV line with 5% glucose. One day after admission; a repeat glucose level was 89 mg%.\nShortly after arrival at the Emergency Department, he developed one episode of brief generalized convulsion with upward gaze and episode lasting for around 30 s, 5 mg of IV diazepam was administered and a contrast-enhanced computed tomography (CT) scan of the brain was promptly performed. The latter showed no evidence of intracranial ischemic or hemorrhagic lesions. Serum lidocaine concentration 30 min after the onset of seizures was 5.1 μg/ml. There were no further seizures; the patient remained stable and was discharged 2 days after admission.
Patient 3 was a 71-year-old male with partial tear of the left rotator cuff who received an arthroscopic rotator cuff repair. The patient had an unremarkable medical history. The positioning of the patient applied during surgery was the beach chair position. An ISB combined with TIVA was planned as the anesthetic strategy. Left ISB was performed by injecting a single-dose of 1% lidocaine (20 mL) and 0.75% ropivacaine (20 mL) followed by continuous interscalene infusion of 0.2% ropivacaine at 6–8 mL/h. There was a negative aspiration test for blood and cerebrospinal fluid prior to injection. Advancement and placement of the catheter was performed in PNS technique using a stimulating catheter. Physical examination prior to surgery confirmed an effective interscalene block. Adverse cardiac or neurologic symptoms were not recorded. For the entire duration of surgery, the patient remained hemodynamically stable and the case proceeded uneventfully under general anesthesia. Immediately after termination of TIVA, and extubation in the OR, the patient presented a considerable delay of waking reactions and aphasia, left-sided gaze preference, severe right-sided central facial palsy, and right-sided severe hemiparesis graded as 1/5 according to the MRC scale for muscle strength. These symptoms persisted during postoperative monitoring in the postanesthesia care unit. Brain imaging three to four hours post-surgery did not detect any cerebral lesions.