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 43-year-old male presented to the emergency department (ED) for evaluation of acute respiratory arrest. Prior to arrival, the patient was at an outpatient surgical center being prepared for a right shoulder arthroscopic surgery under regional anesthesia. The anesthesiologist injected 10 mL of bupivacaine and 30 mL of ropivacaine, of unknown concentrations, while attempting to perform an interscalene block. Soon thereafter, the patient complained of difficulty breathing and subsequently developed complete paralysis and respiratory arrest requiring emergent endotracheal intubation prior to hospital arrival. No additional medications were administered at the time of intubation.\nPhysical exam revealed dilated pupils nonreactive to light, complete flaccid paralysis and inability to withdraw from noxious stimuli. The patient immediately received two liters of 0.9% normal saline and a dopamine infusion, initiated at 5 mcg/kg/min, due to persistent bradycardia (heart rate of 44 bpm) and hypotension. The local poison control center was contacted for recommendations on potential LAT. The decision was made to administer 20% ILE, with a bolus of 125 mL (1.5 mL/kg) over one minute, about 90 minutes after presentation. Shortly after, propofol was initiated for post-intubation sedation at 10 mcg/kg/min. The remaining volume of ILE (125 mL) was then immediately infused over two hours at a rate of 0.013 mL/kg/min.\nApproximately 30 minutes after the initiation of ILE, the patient began to regain brainstem reflexes and eye movement, which progressed to head nods, then movement of his upper extremities. In addition, during that time period, his blood pressure and heart rate improved to within normal parameters. Sixty minutes later, the patient was able to communicate by writing down responses to questions. One hour after that, he had full recovery and was extubated. The patient recovered completely without any evidence of neurological sequelae and was discharged 30 hours after presentation.