Background and Aims Local anesthetics (LA) are widely used for anesthetic care with different routes of administration. Maximum allowable doses of LA are not evidence-based nor consider the site or technique of administration or patient factors.
Results A 71-years-old woman with 65 Kg, ASA II (arterial hypertension and dementia), was admitted for an elective spine fusion under combined anesthesia. We started with an ultrasound-guided bilateral erector spine block with 40 ml of ropivacaine 0.375%. Then, total intravenous anesthesia with propofol and remifentanil TCI was chosen with lidocaine (1mg/kg/h) and ketamine (0,2mg/kg/h) infusions. After 4 hours of uneventful surgery, the patient was extubated and transported to the post-anaesthetic care unit where she had a tonic-clonic seizure controlled with 5mg of midazolam. To exclude the possibility of LAST, despite hemodynamic stability, an intralipid bolus and infusion were initiated. Cerebral tomography was performed showing an intraparenchymal hemorrhage involving the right cerebellar parenchyma with mass effect and reduction of the IV ventriculus. The patient passed away after 10 days in the intensive care unit.
Conclusions Management of these cases needs a multidisciplinary approach. Despite its rareness, remote cerebellar hemorrhage is a possible complication of spine surgery. However, it could also be an anesthetic side effect as very high plasma concentrations of lidocaine can result in seizures and multiple interventions of local anesthetics (MILANA) increases the risk of LAST.
Reviewing the literature, there is a dearth of studies discussing MILANA toxicity, its safety and effectiveness doses, which highlights the importance of considering LAST whenever LA are used.
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