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Anesth Analg 2003;96:1188-1190
© 2003 International Anesthesia Research Society

REGIONAL ANESTHESIA

Seizure After Levobupivacaine for Interscalene Brachial Plexus Block

James C. Crews, MD*, and Theodore E. Rothman, MD{dagger}

Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Address correspondence to James C. Crews, MD, Department of Anesthesiology, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157-1009. Address e-mail to jcrews{at}wfubmc.edu


   Abstract
Top
 Abstract
Introduction
 Case Report
 Discussion
 References
 

IMPLICATIONS: This case report describes a patient who demonstrated generalized seizure activity after an injection of 30 mL of levobupivacaine 0.5% for interscalene brachial plexus block. No evidence of cardiovascular toxicity was noted.


   Introduction
Top
 Abstract
 Introduction
Case Report
 Discussion
 References
 
The single isomer local anesthetics ropivacaine and levobupivacaine were developed as safer alternatives to racemic bupivacaine. Several case reports of central nervous system (CNS) toxicity after injection of ropivacaine for neural block procedures have been reported (1–8) , and a single case report has been published about CNS toxicity after injection of levobupivacaine during epidural anesthesia (9). There have been no published cases of fatal (or serious) cardiac toxicity with either of the single-isomer local anesthetics ropivacaine or levobupivacaine.

We report a patient who experienced a seizure after injection of levobupivacaine for interscalene brachial plexus neural block. No cardiac arrhythmias or other signs of cardiovascular toxicity were observed, and the patient had a complete recovery, offering additional evidence that levobupivacaine may lack the propensity of bupivacaine for concurrent cardiovascular and CNS toxicity.


   Case Report
Top
 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 27-yr-old woman underwent an uneventful general anesthetic for an open anterior repair for a history of recurrent shoulder dislocation. She was otherwise healthy except for a history of asthma, intermittent bronchitis, and obesity (weight, 91 kg; body mass index, 34). Preoperative medications included albuterol and salmeterol inhalers and hydrocodone-acetaminophen for pain. General anesthesia was induced with propofol 200 mg and was maintained with inhaled sevoflurane and nitrous oxide in oxygen via a laryngeal mask airway. The patient arrived in the postanesthesia care unit awake and reporting moderate to severe shoulder pain at the operative site. A brachial plexus block was requested for postoperative analgesia.

The patient received supplemental oxygen 2 L/min by nasal cannulae. The right side of the neck was cleansed with povidone-iodine solution, and a 24-gauge 2.54-cm short bevel insulated stimulating needle (Stimuplex®, B. Braun Medical Inc, Bethlehem, PA) was introduced between the anterior and middle scalene muscles at the level of the cricoid cartilage. Correct needle placement at a depth of approximately 1.5 cm was confirmed with deltoid muscle stimulation with <0.5 mA of current using a Stimuplex®-DIG nerve stimulator (B. Braun) at a frequency of 2 Hz. Aspiration of fluid was attempted before injection and after each 5-mL incremental dose of local anesthetic. A total volume of 30 mL of levobupivacaine 0.5% (Chirocaine®, Purdue Pharma LP, Stamford, CT) with epinephrine 150 µg (1:200,000 concentration) and clonidine 50 µg was injected over a period of approximately 90 s. No blood or fluid could be aspirated at any time before or during the injection. No change in heart rate was noted on continuous electrocardiographic (ECG) and pulse oximetry monitoring during the injection. Tactile and vocal contact was maintained with the patient during and after the neural block procedure.

Within 30 s of completion of the levobupivacaine injection, the patient developed generalized tonic-clonic seizure activity. Oxygen was administered by bag and mask apparatus, and the airway was maintained with routine repositioning of the patient’s head and neck. Midazolam 4 mg IV was administered. Seizure activity ceased after a total duration of approximately 2 min. No ECG changes were noted with the exception of an increase in heart rate from 76 bpm to 120 bpm with intermittent seizure movement artifact on the monitor. The pulse remained regular throughout the episode without evidence of cardiac arrhythmia. The patient’s blood pressure remained stable throughout the episode within the 84–110 mm Hg systolic range (baseline pressure 92 mm Hg).

After the seizure and the administration of midazolam, the patient remained sedated and unresponsive for approximately 50 min, after which she became responsive but initially disoriented and agitated. She responded to verbal reassurance. A 12-lead ECG was obtained that revealed normal sinus rhythm with a normal axis and intervals. Over the course of the next hour, the patient’s arterial oxygen saturation decreased to 90% despite supplemental oxygen administration at 6 L/min by face shield. A chest radiograph revealed no pneumothorax or ipsilateral hemidiaphragmatic increase but some basilar atelectasis and moderate pulmonary edema.

The patient had no evidence of sensory block to pinprick but nevertheless reported adequate analgesia. She remained in the postanesthesia care unit for a total recovery period of 4 h and was then transferred to an intermediate care area for continued observation. Because of the postoperative finding of pulmonary edema, the patient remained in the hospital overnight. Her oxygen saturation returned to baseline within 12 h, and she was discharged home in stable condition on the first postoperative day. The pulmonary insufficiency was felt to be secondary to postobstructive pulmonary edema. She received oral oxycodone for postoperative pain with the first dose request made approximately 6 h after the local anesthetic injection. The patient fully recovered with no other postoperative problems or complications.


   Discussion
Top
 Abstract
 Introduction
 Case Report
 Discussion
References
 
This report describes a case of generalized seizure after injection of levobupivacaine for neural blockade. Despite the occurrence of generalized tonic-clonic seizure activity after presumed IV injection, this patient demonstrated no evidence of local anesthetic cardiovascular toxicity or instability.

CNS or cardiovascular toxicity may result from accidental IV injection, rapid systemic uptake, or relative overdosage of local anesthetics. Reports of deaths after unintentional intravascular injection of local anesthetics, especially bupivacaine and etidocaine during attempted epidural anesthesia in obstetric patients (10), led to changes in regional anesthetic practice (Table 1). Awareness of the potential for serious cardiotoxicity with racemic bupivacaine also initiated the search for potentially safer alternatives to bupivacaine.


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  		Table 1. Common Practices to Reduce the Occurrence of Local Anesthetic Toxicity During Major Peripheral Neural Block Procedures
 
Reports of stereoselective differences in the activity of local anesthetics on cardiac ion channels led to the development of single isomer local anesthetics for clinical use. For the propyl and butyl moieties of the N-alkyl piperidine 2,6-xylidine class of local anesthetics, the S(-) enantiomers (ropivacaine and levobupivacaine) have a smaller risk of causing serious cardiotoxicity than racemic bupivacaine (11–19) .

Whereas several cases of CNS toxicity have been reported after intravascular injection of ropivacaine and levobupivacaine (Table 2), no cases of serious cardiotoxicity or death have been reported in the literature. The incidence of seizure after peripheral neural block with local anesthetic-induced systemic toxicity is approximately two seizures per 1000 procedures (20–22) . Cardiovascular complications associated with local anesthetic-induced seizure have a much smaller incidence, even when bupivacaine is used as the primary local anesthetic (20,21) . It must be noted that bupivacaine had been in clinical use for several years before the cardiotoxicity potential of this drug was recognized and reported in the literature (10).


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  		Table 2. Toxic Manifestations After Neural Block Procedures in Adults Receiving Ropivacaine or Levobupivacaine
 
Whereas serious cardiotoxicity with either of these single isomer local anesthetics is possible, these cases of local anesthetic-induced seizures without serious cardiac toxicity with ropivacaine and levobupivacaine support the claim that these drugs may be a safer alternative to racemic bupivacaine. This case report also demonstrates that intravascular injection of local anesthetic may occur despite adherence to common clinical regional anesthetic practices developed to reduce this occurrence.


   References
Top
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

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Accepted for publication December 5, 2003.




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This Article
Right arrow Abstract Freely available
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Right arrow Articles by Crews, J. C.
Right arrow Articles by Rothman, T. E.
Related Collections
Right arrow Complications
Right arrow Regional Anesthesia

Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins and Stanford University Libraries' HighWire Press®. Copyright 2003 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press