Abstract Introduction An 18-year-old 55.5 kg woman presented to a surgery center for right foot bridge plate removal after a fracture stabilization. Regional anesthesia under ultrasound guidance was attempted, using 37.5 mg bupivacaine and 300 mg mepivacaine as the local anesthetic. Immediately after anesthetic administration, the patient developed seizure-like movements. 20% Intravenous Lipid Emulsion (ILE) (500 mL) was administered due to concerns for Local Anesthetic Systemic Toxicity Syndrome (LAST). Seizure activity resolved with lorazepam (1mg) and the procedure was then completed. Postoperatively, the patient developed recurrent seizure-like movements and received additional ILE (500 mL) and was subsequently transferred to our hospital for further care. Immediately prior to transfer, a third infusion of ILE (500 mL) was administered. Cumulatively, the patient received 1.5L of ILE over approximately 3 hours for LAST. The patient arrived alert without distress, reporting only mild headache. Her neurologic exam revealed no deficits. Toxicology was consulted for management of LAST. Soon after arrival, medical staff were notified that the patient developed crescendoing headache with intractable pain, photophobia, and cervicalgia. Over the next hour, pain intensified despite treatment with intravenous opioids. Blood draw was unsuccessful with existing intravenous access owing to high blood viscosity. A large bore needle was required to obtain blood revealing highly viscous and turbid blood with lipid layering (see Figure 1). No laboratory data was able to be obtained on initial samples due to the blood sample’s gross lipemia. Insulin infusion and crystalloids were initiated. Ultimately, the degree of lipemia along with the character and trajectory of symptoms raised concern for Hyperviscosity Syndrome. Therapeutic Plasma Exchange (TPE) was performed which yielded dramatic improvement in the patient’s clinical status. Laboratory assessment later revealed elevated creatinine and a significantly elevated triglyceride level (10,350 mg/dL). Discussion This case highlights the risk of iatrogenic toxicity from supratherapeutic dosing of ILE. The cumulative dose of ILE was not clear to the primary or consulting teams at the time of the patient’s presentation, but rapid clinical and immediate multidisciplinary response between critical care, toxicology, and pathology enabled timely diagnosis and management. TPE was initiated within hours of the patient’s arrival to our hospital. With appropriate treatment, serum triglycerides decreased to 90 mg/dL and the patient’s symptoms resolved. The patient was discharged less than 48-hours after admission without signs of end organ damage or residual neurologic signs or symptoms, except for mild headache that did persist several weeks beyond discharge. This abstract is funded by: None
McKamie et al. (Fri,) studied this question.