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LETTER TO THE EDITOR

Drug Interaction or Drug Overdose? Supercaine Revisited

Department of Anesthesiology; University of Illinois College of Medicine; Chicago, IL; guyw{at}uic.edu (Weinberg) Jesse Brown VA Medical Center; Chicago, IL (VadeBoncouer)

To the Editor:

We read with great interest the article of Marcucci et al. (1) illustrating the contribution of drug–drug interactions to a case of intraoperative cardiac arrest. They attribute the event to an exaggerated effect of metoprolol. We believe local anesthetic toxicity is often overlooked (2) and were disappointed that the authors did not consider the interaction of tetracaine and mepivacaine in the differential diagnosis of a patient who experienced asystole and contractile depression after a brachial plexus block. Moore et al. (3) confirmed the safety of this popular combination when the total mepivacaine dose was limited to 500 mg. However, the reported patient received 675 mg mepivacaine plus 50 mg tetracaine which, in view of their additive toxicities, might have contributed to the patient’s cardiovascular symptoms. Furthermore, the patient’s weight was not reported, and we think it is very important, particularly when combining local anesthetics, to be mindful of the total dose of drug per kilogram of lean body mass. This is especially appropriate when, as the authors postulate, the patient’s genetic, metabolic, dietary, and medical milieu lowered the threshold for toxicity of such agents.

The patient received ephedrine, epinephrine, dopamine, phenylephrine, and norepinephrine during his resuscitation. Aggressive adrenergic therapy is associated with adverse outcomes in several models and studies of cardiac arrest (4,5). A recent survey by Corcoran et al. (6) indicates that there is a lack of consensus among anesthesiologists regarding proper treatment of severe local anesthetic toxicity. In light of two recent case reports (7,8), we recommend considering lipid infusion (9,10) as an adjunct to other modes of therapy in cases of local anesthetic toxicity.

We did not obtain a response from Marcucci et al.

REFERENCES

1. Marcucci C, Sandson NB, Thorn EM, Bourke DL. Unrecognized drug-drug interactions: a cause of intraoperative cardiac arrest? Anesth Analg 2006;102: 1569–72[Abstract/Free Full Text]
2. Schwartz D, VadeBoncouer T, Weinberg G. Was case report a case of unrecognized local anesthetic toxicity? Anesth Analg 2003;96:1844–5[Free Full Text]
3. Moore DC, Bridenbaugh LD, Bridenbaugh PO, Thompson GE, Tucker GT. Does compounding of local anesthetic agents increase their toxicity in humans? Anesth Analg 1972;51:579–85[Free Full Text]
4. Zhong JQ, Dorian P. Epinephrine and vasopressin during cardiopulmonary resuscitation. Resuscitation 2005;66:263–9[Web of Science][Medline]
5. McCaul CL, McNamara PJ, Engelberts D, Wilson GJ, Romaschin A, Redington AN, Kavanagh BP. Epinephrine increases mortality after brief asphyxial cardiac arrest in an in vivo rat model. Anesth Analg 2006;102:542–8[Abstract/Free Full Text]
6. Corcoran W, Butterworth J, Weller RS, Beck JC, Gerancher JC, Houle TT, Groban L. Local anesthetic-induced cardiac toxicity: a survey of contemporary practice strategies among academic anesthesiology departments. Anesth Analg 2006;103:1322–6[Abstract/Free Full Text]
7. Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB. Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology 2006;105:217–18[Web of Science][Medline]
8. Litz RJ, Popp M, Stehr SN, Koch T. Successful resuscitation of a patient with ropivacaine-induced asystole after axillary plexus block using lipid infusion. Anaesthesia 2006;61:800–1[Medline]
9. Groban L, Butterworth J. Lipid reversal of bupivacaine toxicity: has the silver bullet been identified? Reg Anesth Pain Med 2003;28:167–9[Web of Science][Medline]
10. Weinberg G, Ripper R, Feinstein DL, Hoffman W. Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity. Reg Anesth Pain Med 2003;28:198–202[Web of Science][Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Weinberg, G. Articles by VadeBoncouer, T. Search for Related Content PubMed PubMed Citation Articles by Weinberg, G. Articles by VadeBoncouer, T.