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CNS and heart disorders treated with soya oil emulsion: case report A 36-year-old man developed CNS and heart disorders including headache, dizziness, diplopia, tachycardia, hypertension and ST segment depression following lidocaine and bupivacaine injection. Subsequent treatment with soya oil emulsion [Intralipid] was successful. The man had a history of chronic leg pain, femoral-popliteal deep vein thrombosis, lower limb compartment syndrome and painful spasms of his leg. He had undergone fasciotomy and myomectomy of his gastrocnemius, and surgical decompression and neurolysis of his popliteal nerve. He was admitted with intractable pain and spasm of his right lower leg involving virtually all groups of muscles innervated by the common fibular and tibial nerves. The spasms proved resistant to lidocaine, benzodiazepines and opioid infusions. Over the subsequent 3 weeks, he received regular intramuscular local anaesthetic injections, intramuscular botulinum toxin A injections, several nerve blocks, epidural infusions, selective phenol nerve ablations, and finally radiofrequency ablations of the tibial and common fibular nerves. On one occasion, a mixture of 10mL of 1% lidocaine (with epinephrine [adrenaline] 1:200 000) and 20mL of 0.5% bupivacaine were injected into his soleus and extensor hallucis longus muscles for pain and spasm relief. Within 60 seconds of administration, he developed perioral tingling, dizziness, headache, light headedness and diplopia, which were quickly followed by an HR of 153 beats/minute, a BP of 180/110mm Hg, and ST segment depression in the anterior and lateral chest leads on his ECG. The rapid onset of symptoms led to the suspicion of local anaesthetic toxicity. The man received Hartmann’s solution and oxygen. Within 5 minutes, he received two boluses of 20% soy oil emulsion, with each bolus lasting 1–3 minutes. Within the first minute of soya oil emulsion administration, his symptoms dramatically improved, and his HR and BP decreased to 92 beats/minute and 158/105mm Hg, respectively. His diplopia, headache and faintness also subsided quickly. He received an addition 100mL soya oil emulsion infusion over 1 hour, and was admitted to the intensive care unit (ICU). Repeat ECG on discharge from the ICU showed complete reversal of the ST segment change. Author comment: "A few human case reports now exist demonstrating use of Intralipid 20% where local anesthetic (LA) has caused central nervous system toxicity. We would like to add a case to the literature regarding the successful use of Intralipid in the treatment of LA-induced central nervous system toxicity." Espinet AJ, et al. The successful use of intralipid for treatment of local anestheticinduced central nervous system toxicity: Some considerations for administration of intralipid in an emergency. Clinical Journal of Pain 25: 808-809, No. 9, Nov-Dec 2009. Available from: URL: http://dx.doi.org/10.1097/AJP.0b013e3181af739e 803007109 Australia

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