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Bupivacaine crystal deposits after long-term epidural infusion

Bupivacainkristalle nach epiduraler Langzeitinfusion

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Abstract

The case of a 45-year-old male patient (body weight 52 kg, height 1.61 m) with a locally invasive gastric carcinoma infiltrating into the retroperitoneal space is reported. Because of severe cancer pain a tunnelled thoracic epidural catheter (EC) was placed at thoracic spinal level 7/8 and a local anesthetic (LA) mixture of bupivacaine 0.25 % and morphine 0.005 % was infused continuously at 6 ml h−1. To optimize pain therapy the concentration was doubled (bupivacaine 0.5 %, morphine 0.01 %) 3 months later but the infusion rate was reduced to 3 ml h−1 thus the total daily dose did not change. The patient died 6 months after initiation of the epidural analgesia from the underlying disease. The total amount of bupivacaine infused was 69 g and of morphine 1.37 g. The patient never reported any neurological complications. The autopsy revealed large white crystalline deposits in the thoracic epidural space which were identified as bupivacaine base by infrared spectrometry. Morphine could not be detected. A histological examination showed unreactive fatty tissue necrosis within the crystalline deposits but nerve tissue could not be identified. It is concluded that the bupivacaine crystalline deposits arose due to precipitation but the clinical significance with regard to sensory level and neuraxial tissue toxicity is unknown.

Zusammenfassung

Berichtet wird über einen 45-jährigen Patienten (Körpergewicht 52 kg, Körpergröße 1,61 m) mit lokal invasivem, das Retroperitoneum infiltrierendem Magenkarzinom. Wegen starker Tumorschmerzen wurde ein getunnelter Epiduralkatheter auf der Höhe Th7/8 zur kontinuierlichen Infusion (6 ml/h) einer lokalanästhetisch wirkenden Kombination aus 0,25%igem Bupivacain und 0,005%igem Morphin gelegt. Zur Therapieoptimierung wurden 3 Monate später die Konzentration verdoppelt (0,5%iges Bupivacain und 0,01%iges Morphin) und die Infusionsrate halbiert (3 ml/h), sodass sich die tägliche Dosis nicht veränderte. Sechs Monate nach Beginn der Epiduralanalgesie verstarb der Patient an seiner Grunderkrankung. Insgesamt waren 69 g Bupivacain und 1,37 g Morphin infundiert worden. Zu keiner Zeit hatte der Patient neurologische Komplikationen angegeben. In der Autopsie fanden sich großflächige weiße kristalline Ablagerungen im thorakalen Epiduralraum, infrarotspektrometrisch erwiesen sich diese als aus Bupivacain bestehend. Morphin konnte nicht nachgewiesen werden. Die histologische Untersuchung zeigte eine nichtreaktive Fettgewebsnekrose innerhalb der Bupivacainkristalle; Nervengewebe ließ sich nicht identifizieren. Es wird davon ausgegangen, dass die Bupivacainkristalle durch Präzipitation entstanden sind. Nicht bekannt ist ihre klinische Bedeutung auf sensorischer Ebene und hinsichtlich einer neuroaxialen Gewebetoxizität.

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Acknowledgment

The authors thank Mr. Maurice Hogan, M.D., and Mr. Menish Soni, M.D., for excellent support.

Conflict of interest

The corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Department of Anaesthesiology, Surgical Intensive Care, Emergency Care Medicine and Pain Medicine, Kantonsspital Lucerne, Lucerne, Switzerland

    I. Balga M.D. & H. Gerber M.D.

  2. Pharmacy, Kantonsspital Lucerne, Lucerne, Switzerland

    X.H. Schorno

  3. Department of Pathology, Kantonsspital Lucerne, Lucerne, Switzerland

    F. Aebersold Keller M.D. & H.-P. Oehen M.D.

  4. Department of Anaesthesiology and Intensive Care Medicine, Heartcenter Leipzig, University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany

    I. Balga M.D.

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  1. I. Balga M.D.
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  2. H. Gerber M.D.
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  3. X.H. Schorno
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  4. F. Aebersold Keller M.D.
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  5. H.-P. Oehen M.D.
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Correspondence to I. Balga M.D..

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Balga, I., Gerber, H., Schorno, X. et al. Bupivacaine crystal deposits after long-term epidural infusion. Anaesthesist 62, 543–548 (2013). https://doi.org/10.1007/s00101-013-2179-5

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  • DOI: https://doi.org/10.1007/s00101-013-2179-5

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