Bupivacaine(BUP) has an advantage over other local anesthetics because of its long-acting sensory anesthesia, but because of its high affinity for the myocardial Na+ channel it can be cardiotoxic. Levobupivacaine(LBUP) is an S(-)-isomer of the racemate BUP, and dexbupivacaine(DBUP) is an R(+)-isomer. LBUP has less neuronal and cardiac toxicity than BUP and DBUP, but DBUP induces more negative chronotropism and arrhythmogenic effects than either LBUP or BUP.
A 76-year-old man with a permanent pacemaker was scheduled for transurethral lithotripsy. He had a past history of drug allergy, which we were not informed preoperatively. About 40min after spinal anesthesia, he suddenly developed hypotension which did not respond to intravenous fluids and ephedrine. Subsequently, he became cardiopulmonary arrest and ventricular fibrillation. He was successfully resuscitated without any neurological sequelae. Erythema appeared on the lower abdomen, suggesting the occurrence of anaphylactic shock. The cause of anaphylactic shock was considered to be a disinfectant, chlorhexidine gluconate, or an additive agent, methylparaben.
A 77-year-old man was scheduled for aortic valve replacement to treat his aortic stenosis. After induction of anesthesia with fentanyl and propofol, tracheal intubation was facilitated with vecuronium. A pulmonary artery catheter(PAC) was inserted via the right internal jugular vein without difficulty. The tip of the PAC was seen in the left pulmonary artery on a postoperative chest radiograph. The patient was separated from cardiopulmonary bypass(CPB). During protamine infusion, acute pulmonary hemorrhage occurred through the tracheal tube. Fiberoptic bronchoscopy revealed the right upper bronchus to be the source of bleeding. By this time, 500ml of blood had been lost through the endotrachel tube. The bleeding stopped within 30 minutes without any treatment. We administered aprotinin and antithrombin III to normalize blood clotting. No further bronchial bleeding occurred. We could not identify the cause of hemorrhage, although bronchiectasis, tracheal injury by tracheal intubation, PAC-related perforation of the pulmonary artery, perforation of pulmonary vein by ventricular vent catheter, or a metastatic pulmonary tumor from colon cancer were all considered.