A 56-year-old woman underwent an uncomplicated left shoulder bone spur removal under general anesthesia with 2 mg of versed, 100 mcg of fentanyl, 150 mg of propofol, and sevoflurane in an outpatient surgery center. After completion of the procedure, the anesthesiologist performed an interscalene nerve block for post-operative pain control utilizing 30 mL of bupivacaine (0.25%). Approximately 5 min after completion of the block, the patient developed bilateral mydriasis, paralysis of all extremities, and respiratory arrest. The patient was immediately intubated, administered IV fluids, ephedrine 15 mg IV, and transferred to an emergency department (ED).\nOn ED arrival the patient was being ventilated through an oral endotracheal tube and was completely paralyzed. Her vital signs were: blood pressure (BP) 108/56 mmHg; pulse 86 per minute; respiratory rate 24 breaths per minute on a ventilator. Her pupils were 6 mm and unresponsive to light bilaterally. She had no response to painful stimulation and had no spontaneous respirations on a ventilator. Her initial blood tests included a complete blood count, electrolytes, liver function tests, cardiac enzymes, and coagulation tests. The lab results were all unremarkable except for a phosphorus of 1.7 mg/dL and lactate of 4 mmol/L. In the ED she was administered a 1-L normal saline bolus and 20% intravenous lipid emulsion 85 mg. Over the next 4 h, the patient progressively regained motor and sensory functions followed by successful extubation in the ED. She was admitted to the hospital for observation and discharged home the next day without any neurologic sequelae.
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.