Bupivacaine/gadolinium-containing contrast agents
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Cortical blindness and other toxicites: case report A 53-year-old woman developed cortical blindness, hypertension and loss of consciousness after bupivacaine administration into a thoracic epidural catheter; the reactions recurred after a gadolinium-containing contrast agent was administered into the same epidural catheter. The woman had bronchial cancer and was scheduled to undergo tumour resection. Her baseline BP was 175/75 mmHg prior. An epidural catheter was placed at the T2-3 intervertebral space 1 day prior to surgery. The following day 3 mL of 0.5% bupivacaine was injected into the epidural catheter. Within 1 minute of the injection she fell unconscious and could not be roused. Her peak systolic blood pressure increased to 210 mmHg and sufficient respiration was maintained. She regained consciousness 10 minutes after bupivacaine administration and exhibited disorientation and reported seeing ’nothing’. The operation was postponed and she underwent further testing. No intraocular or extraocular explanation for her vision loss was identified by examination. She was diagnosed with cortical blindness on the basis that she could see ’nothing’, including blackness. MRI scanning revealed elevated signal intensity with signs of vasogenic cerebral oedema in the caudal regions of the bilateral temporal areas, left cerebellum and thalamic and occipital segments, confirming cortical blindness. A CT scan showed that correct midline placement of the epidural catheter tip in the dorsal epidural space had occurred and the spinal cord appeared normal. Prior to a subsequent MRI scan, the woman was administered 3 mL of a gadolinium-containing contrast agent [specific drug and dosage not stated] through the epidural catheter in an attempt to enhance visualisation of the catheter. She lost consciousness, was hypertensive with a peak systolic pressure of 240 mmHg, and exhibited convulsions with extensor posturing of her upper and lower extremities 5 minutes after the contrast agent was administered. The woman underwent intubation and mechanical ventilation and was administered nitroglycerin [glyceryl trinitrate] and nicardipine. She regained consciousness 2 days later and was breathing on her own; however, the development of cognitive disorders, including disorientation in time and place and anterograde amnesia in addition to her prior vision loss, was noted. The bupivacaine administered underwent testing and was found to meet the manufacturers finished product specifications. A skin test also ruled out any allergy to bupivacaine. She later returned home and at follow-up 1 year later, her vision loss and cognitive disorders had not significantly improved. Author comment: "The fact that a second episode of loss of consciousness and hypertension occurred after an epidural injection with MRI contrast medium supports the assumption that volume expansion of the epidural space is a more likely culprit than action by the local anaesthetic." Visser WA, et al. Persistent cortical blindness after a thoracic epidural test dose of bu
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