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LETTER TO THE EDITOR

Mepivacaine Overdosage Is More Likely a Cause of Intraoperative Cardiac Arrest than Drug–Drug Interaction

Department of Anesthesiology, Maimonides Medical Center, 4802 Tenth Ave., Brooklyn, NY, dmd{at}maimonidesmed.org

To the Editor:

In a recent case report (1) of intraoperative cardiac arrest after axillary brachial plexus block, the authors described the various families of cytochrome P-450 and the potential for drug interactions. They claim that an unrecognized drug– drug interaction affecting cytochrome P-450 system was responsible for the cardiac arrest. Although inhibition of cytochrome P-450 due to drug interactions may have exacerbated mepivacaine toxicity by decreasing its metabolism, we believe that mepivacaine toxicity, secondary to a large dose, not drug–drug interaction, is responsible for the cardiac arrest. The 675 mg of mepivacaine dose significantly exceeds the recommended maximum dose for brachial plexus block, 400 mg (2). The patient was stable for 10 min, gradually developing bradycardia and hypotension that did not respond to ephedrine and phenylephrine; 60 min later the patient had cardiac arrest. The gradual absorption of a large dose of mepivacaine explains this sequence of events. It is well known in literature (3,4) that systemic toxicity caused by local anesthetic after a brachial plexus block may result in cardiac arrest and seizures.

REFERENCES

1. Marcucci C, Sandson N, Thorn E, Bourke D. Unrecognized drug-drug interactions: a cause of intraoperative cardiac arrest. Anesth Analg 2006;102:1569–72.[Abstract/Free Full Text]
2. Ronald D Miller. Miller’s anesthesia. In: Strichartz GR, Berde CB, eds. Local anesthetics. Philadelphia: Churchill Livingstone, 2005:587–90.
3. Brown DL, Ransom DM, Hall JA, et al. Regional anesthesia and local anesthetic-induced systemic toxicity: seizure frequency and accompanying cardiovascular changes. Anesth Analg 1996;81:321–8.[Web of Science]
4. Edde RR, Deutsch S. Cardiac arrest after interscalene brachial-plexus block. Anesth Analg 1977;56:446–7.[Free Full Text]

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