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Suspected local anesthetic systemic toxicity with ropivacaine after transversus abdominis plane block for postcesarean analgesia: report of two cases
Abstract Number: S1D-5
Abstract Type: Case Report/Case Series
Transversus abdominis plane block (TAPB) after caesarean delivery (CD) is a safe option and provides excellent somatic pain relief. However, local anesthetic systemic toxicity (LAST) has been reported with TAPB. We report 2 cases of suspected LAST with ropivacaine, one of which was given even less than 3 mg/kg of ropivacaine and the other was treated with lipid rescue.
Case 1: a 32-year-old parturient with twin pregnancy and premature rupture of membrane(PROM) at 36 weeks gestation underwent urgent CD under spinal anesthesia. She was standing 152 cm and weighing 55.7 kg with pre-pregnancy body weight (PPBW) of 44 kg. After skin closure, ultrasound-guided TAPB with 0.375% ropivacaine 20mL on each side (total 40 mL) was performed. Sixteen minutes later, rash was noted with upper arm weakness, tremor, and slurred speech. Antihistamine was given for rash, and other symptoms disappeared 1 hour later without further treatment.
Case 2: a 38-year-old parturient with twin pregnancy and PROM at 35 weeks gestation underwent urgent CD under spinal anesthesia. Her height was 153 cm, and her weight was 53.2 kg (PPBW 46 kg). Ultrasound-guided TAPB was done with 0.5% ropivacaine 20 mL on each side immediately after surgery. Twenty minutes later, she developed decreased consciousness along with tinnitus, upper arm tremor, and desaturation. LAST was suspected, and 10% Intralipid® 200 mL was given. Her symptoms improved after lipid rescue, but she needed overnight intensive care due to suspected ritodrine-associated pulmonary edema.
The symptoms in our two patients were not typical of LAST, but the timing after TAPB and resolution of symptoms after lipid rescue in one patient suggest similar etiology of LAST. LAST has been reported even with ropivacaine and levobupivacane after TAPB for CD. The dose of ropivacaine in our cases were 150-200 mg, that were 3.4 mg/kg and 3.75 mg/kg based on PPBW, respectively. We experienced these two cases among 822 blocks in the period of 3 years, when TAPB was almost routinely performed. Our previous audit revealed that 29 patients received ropivacaine greater than 3 mg/kg based on PPBW, which is considered as the maximum recommended dose for ropivacaine. Most physicians would decide the maximum dose of local anesthetic based on the actual body weight, not PPBW. Griffiths reported that TAPB with ropivacaine 2.5 mg/kg based on actual body weight resulted 10% of patients with mild neurotoxic symptoms (1). The sensitivity to LAST could be enhanced during pregnancy because of altering volume distribution or reducing protein binding as well as hormonal effect. Furthermore, the composition of the body does not change in proportion along with increasing body weight. To provide safety-first medical care, the maximum dose of local anesthetic during pregnancy would be considered based on pre-pregnancy body weight.
(1)Griffiths LD, et al. BJA 2013