Abstract
Abstract
Background
Local anesthetic systemic toxicity (LAST) is an uncommon but potentially fatal complication of regional anesthesia, peripheral nerve block, and local anesthetic infiltration. Delayed presentations may occur after fascial plane blocks, tissue infiltration, or long-acting local anesthetic formulations, including liposomal bupivacaine. In critically ill surgical patients, however, postoperative ventricular arrhythmias are often multifactorial, and the diagnosis may remain uncertain.
Case presentation
A 55-year-old man with stage IV chronic kidney disease, hypertension, prosthetic joint infection, and a history of multiple right hip operations underwent hip revision surgery under general anesthesia combined with fascia iliaca block. He received 30 mL of 0.25% ropivacaine for fascia iliaca block, 20 mL of 0.25% ropivacaine for intra-articular injection, and 133 mg of liposomal bupivacaine for wound infiltration. The patient remained intubated and was transferred to the intensive care unit after surgery. At 14:48, approximately 103 minutes after liposomal bupivacaine infiltration and 118 minutes after intra-articular ropivacaine administration, he developed ventricular fibrillation with undetectable arterial pressure. Recurrent ventricular fibrillation and cardiac arrest occurred between 14:48 and 17:41, requiring repeated cardiopulmonary resuscitation, four defibrillations, epinephrine, norepinephrine, amiodarone, correction of metabolic acidosis, blood transfusion, and continuous renal replacement therapy. Intravenous lipid emulsion was not administered. The course was complicated by anemia, coagulopathy, severe hyperlactatemia, infection-related inflammatory response, myocardial injury, and renal dysfunction. The patient was extubated on postoperative day 3. Continuous renal replacement therapy was discontinued on 19 September without subsequent dialysis, vasoactive agents were discontinued on 21 September, and he was transferred to the general ward on 22 September. He was discharged after a 49-day hospitalization.
Conclusions
The temporal relationship between local anesthetic exposure and ventricular fibrillation made delayed LAST a relevant consideration, but the postoperative collapse was more plausibly multifactorial. In similar high-risk patients, delayed LAST should remain in the differential diagnosis while hemorrhage, acid-base and electrolyte disturbances, infection, myocardial injury, pulmonary embolism, and other competing causes are assessed in parallel.