Management of Suspected Local Anesthetic Systemic Toxicity after Caudal Block in an Intubated Pediatric Patient

We present a case of Local Anesthesia Systemic Toxicity (LAST) in a 7-month-old male after a caudal block placement. The patient was a healthy 8.3 kg male without any medical history, surgical history, significant birth history or any history of family problems with anesthesia. After induction of general anesthesia, a size 1.5 laryngeal mask airway (LMA) was placed, and an intravenous line with 22 gauge catheter was placed. The patient was positioned in the right lateral decubitus position. The caudal space was located by palpation, and a 22 g angiocath was easily placed through the sacral hiatus. Neither blood nor CSF was aspirated through the catheter and 1 ml test dose containing 0.25% Bupivacaine + 1:200,000 epinephrine was administered. After a full minute of watching for any EKG changes, the remaining 8 ml of 0.25% Bupivacaine + 1:200,000 epinephrine was slowly injected into the caudal space with intermittent aspiration. Several minutes after the injection, there was a sudden prominent change in the EKG with QRS complex widening on the EKG accompanied by a drop in ETCO₂. 20% Lipid emulsion was administered immediately and a normal EKG pattern returned with a concomitant increase in ETCO₂. The planned procedure was performed, and the patient extubated uneventfully. After being monitored in the PACU for an extended period of time, he was discharged home. Follow-up was unremarkable.