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 1 was a 52-year-old male with a medical history of multiple sclerosis, who underwent arthroscopic rotator cuff repair due to a spontaneous complete rupture of the left supraspinatus tendon. The positioning of the patient applied during surgery was the beach chair position. Preoperative blood pressure (BP) was 135/80 mm Hg; heart rate (HR) 66 beats per minute (bpm); oxygen saturation (SpO2) values between 98% and 100%. For premedication, the patient received orally administered midazolam. Single-injection ISB was performed prior to induction of anesthesia and intubation. Total intravenous anesthesia (TIVA) was maintained with propofol and sufentanil. For left ISB, the patient initially received single-dose injections of 1% lidocaine (20 mL) and 0.75% ropivacaine (20 mL) followed by a second single-dose injection of 0.75% ropivacaine (10 mL) three hours after initial local anesthetic injections and 15 min prior to termination of TIVA, and extubation. Safety checks prior to injection did not show any aspiration of blood or cerebrospinal fluid. Adverse cardiac or neurologic symptoms were not recorded. Advancement and placement of the catheter was performed in PNS technique using a stimulating catheter. An effective ISB was confirmed by physical examination prior to surgery. BP was measured every 5 min with a noninvasive cuff. The patient underwent an uneventful operative rotator cuff repair under the ISB and intravenous anesthesia. Intraoperatively, recorded systolic blood pressure (SBP) levels of 100–110 mmHg were interrupted by SBP levels of ≥90 and <100 mmHg for a maximum of 90 min due to the application of controlled hypotension. Administration of antihypertensive and/or vasoconstrictor drugs was not recorded. SpO2 (98% to 100%), and end-tidal CO2 (ETCO2) values (30% to 34%) were normal throughout the case. The duration of surgery was 170 min. After termination of TIVA, and extubation in the operating room (OR), the patient remained in a severely impaired conscious state. In the postanesthesia care unit the patient showed a sustained severe impairment of consciousness, and neurological examination by a neurologist additionally revealed aphasia, multi-modal neglect to the right, left-sided gaze preference, dysphagia, severe right-sided central facial palsy, severe right-sided hemiparesis graded as 2/5 according to the Medical Research Council (MRC) scale for muscle strength, right-sided positive pyramidal tract signs, and right-sided hemihypesthesia. These symptoms were further accompanied by complex behavioural manifestations (anxiety, vocalization, aggression) and facial motor movements suggesting complex focal seizures. Due to vomiting with pulmonary aspiration, the patient underwent an emergency intubation. Brain imaging four hours post-surgery did not detect any cerebral lesions.