Lipid rescue for treatment of delayed systemic ropivacaine toxicity from a continuous thoracic paravertebral block

A 66-year-old man underwent a left minithoracotomy for pleural biopsies and thoracentesis. A left T3 paravertebral catheter was placed prior to induction of general anaesthesia, and a total of 20 mL of bupivacaine 0.25% administered. Postoperatively, ropivacaine 0.2% infusion was commenced at 10 mL/hour. Thirty-seven hours after the initial block, the patient developed convulsions without loss of consciousness. The ropivacaine infusion rate was unchanged and no further boluses had been given. He reported of perioral tingling, a burning sensation in his legs and penis and agitation. Ropivacaine infusion was ceased and a bolus of lipid emulsion (Intralipid 20%) administered, followed by an infusion. His symptoms (aside from mild agitation) resolved within an hour of cessation of the local anaesthetic and commencement of lipid rescue. The total serum concentration of ropivacaine during the event was 2.1 mg/L compared with a published toxic level of 2.2 mg/L in healthy human volunteers.