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Bundle Branch Block Following Lidocaine and Neuraxial Anesthesia
Abstract Number: RF3AC-390
Abstract Type: Case Report Case Series
INTRODUCTION: Transient bundle branch blocks (BBB) are rare and usually occur in patients with known cardiac risk factors.(1) We present a healthy patient who experienced a LBBB following lidocaine administration during neuraxial anesthesia.
CASE: A 37 y/o G2P1 BMI 42.5 at 39.1 weeks gestation presented for scheduled repeat cesarean delivery (CD) with planned combined spinal and epidural. Her pregnancy was via IVF with third trimester polyhydramnios. She had an uncomplicated CD 23 years prior and controlled hypothyroidism.
Pulse oximeter and blood pressure cuff were applied in the operating room. EKG lead placement was deferred until after CSE placement. We decided to proceed solely under epidural anesthesia because CSF flow was not obtained despite easy identification of anatomic landmarks. Initial test dose of 3cc 1.5% lidocaine with 1:200,000 epinephrine was notable for tachycardia without hypertension. A second test dose was negative. She was positioned supine, EKG leads were applied, and a surgical level of anesthesia was obtained with 3% chloroprocaine.
Following placement of EKG leads, the patient was noted to be in normal sinus rhythm (NSR), but quickly developed a LBBB, confirmed by 12 lead EKG. The patient denied pain or dyspnea. Her rhythm converted between LBBB and NSR without ST changes. Troponins were sent, cardiology was consulted for post-operative assessment, and an uncomplicated CD proceeded. Troponins and post-operative echocardiogram were unremarkable. Over the next 24 hours, the patient spontaneously reverted to NSR.
Transient BBBs have been reported with lidocaine and neuraxial anesthesia, usually in patients with cardiac risk factors.(2) Here it occured in a healthy parturient. Because this patient had no indication for preoperative cardiac testing and it is not our routine practice to apply EKG leads before neuraxial anesthesia, we could not confirm if this was a new conduction abnormality or the discovery of an underlying rhythm. New LBBB raised concerns for peri-partum cardiomyopathy, local anesthetic toxicity, and ischemia.(3) While early recognition, interdisciplinary communication, and low pre-test probability of a cardiac event allowed us to proceed, the identification of this phenomenon will help inform decision making in more complicated patients.
(1) Tagliente: Anesth Analg 1989; 69.4: 545
(2) Asao: Masui 1996; 45.5: 483
(3) Labidi: Eur Heart J 2011; 32.9: 1076