A 54-year-old man presented to the hospital with dyspnea after inhaling butane gas while melting a water pipe during winter. On physical examination, late inspiratory crackles were evident in both auscultated lower lung fields. His history showed no lidocaine allergy, allergic rhinitis, asthma, or allergies to other drugs. On examination, blood pressure was 125/75 mmHg, pulse was 65 beats per minute, oral temperature was 36.5℃, respiratory rate was 18 breaths per minute, oxygen saturation was 76.0%, pH was 7.27, PaO2 was 46.0 mmHg, and PaCO2 was 47.2 mmHg, as the patient breathed ambient air. Total IgE was 129 kU/L. An electrocardiogram revealed a normal sinus rhythm. A pulmonary function test revealed forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) of 78%, FVC of 2.24 L (60%), FEV1 of 1.75 L (62%), and a diffusing capacity for carbon momoxide of 15.1 mL/mmHg (71%) indicating a restrictive pattern. Chest radiographs revealed bilateral patchy opacities, more in the right lung than in the left lung. Computed tomography of the chest revealed multifocal consolidation and ground-glass opacities in all lobes of both lungs, indicating an acute inhalation lung injury (). The patient recovered after oxygen and supportive care. On the fifth day, we planned to conduct a bronchoscopy to diagnose an inhalational lung injury. We used lidocaine aerosol as local anesthesia for reducing the gag reflex. After administering the lidocaine anesthesia, the patient complained of dizziness without urticaria and angioedema and shortness of breath, which was associated with an increased respiratory rate and decreased oxygen saturation. Coarse expiratory wheezes were auscultated on a physical examination. Blood pressure subsequently dropped, and a radial pulse was not palpable. The patient was treated with nebulized salbutamol and systemic steroid. However, the patient did not recover, and blood pressure continued to decrease accompanied by an increase in respiratory rate and a decrease of oxygen saturation () followed by cardiorespiratory arrest. Cardiopulmonary resuscitation (CPR) with epinephrine, inotropics, and fluid therapy was performed immediately, and the patient was admitted to the intensive care unit under tracheal intubation and ventilator treatment. After 2 hours, his CPR tryptase level was 1.68 µg/L. He was extubated safely on the third post-CPR day.
A 54-year-old female patient, weighing 77 kg, experienced various symptoms such as clouding of consciousness, hearing impairment, and chills during dental treatment for periodontal disease using a local anesthetic. Under the assumption that these adverse effects were attributable to the use of lidocaine, the patient was transferred to the Department of Allergy to determine whether local anesthesia with bupivacaine would be possible.\nThe Department of Allergy performed skin prick and intradermal tests to test for reactivity to bupivacaine, and the patient tested negative in the skin prick test. In the skin provocation test, when administered an intradermal injection of 0.1 cc bupivacaine diluted to 1:100, the patient complained of listlessness and drowsiness beginning 30 s after the injection. Following an intradermal injection of 0.1 cc bupivacaine diluted to 1:10, the patient's symptoms of listlessness and drowsiness became more severe from 30 s after the injection. When administered an intradermal injection of 0.1 cc of undiluted bupivacaine, the patient was placed in a recumbent position on a bed owing to complaints of listlessness and heavy eyes at approximately 50 s after the injection. Subsequently, the patient showed symptoms of shivering, which eventually became uncontrollable, and she had difficulty keeping her eyes open. As a result, the patient was given 2 doses of 0.5 mg Ativan. Afterward, the patient appeared to be more stable, but began showing symptoms of shaking her chin and one of her arms, for which 0.5 ampule of Demerol™ was administered, after which her condition began to improve. The testing was completed within 20 min and the patient was discharged after a 5 h observation period. The patient was diagnosed with bupivacaine intolerance, meaning the appearance of adverse effects even with small amounts of the medication, and the dental treatment was subsequently performed under general anesthesia since local anesthesia was determined to be impossible.