Case discussion and root cause analysis: bupivacaine overdose in an infant leading to ventricular tachycardia

Area of Science:

• Pediatric Anesthesiology
• Patient Safety
• Pharmacology

Background:

• Elective circumcision is a common pediatric procedure.
• Local anesthetics, such as bupivacaine, are frequently used for pain management.
• Safe administration requires precise dosing and vigilant monitoring.

Observation:

• An 11-month-old infant received an excessive dose of 0.5% bupivacaine for a penile block.
• The patient developed ventricular tachycardia post-administration.
• Immediate resuscitation with intralipid resulted in an uneventful recovery.

Findings:

• A root cause analysis identified a critical communication failure among the surgical and anesthesia team.
• Lack of communication regarding maximum local anesthetic dosage was the proximate cause.
• Systemic issues in medication preparation and verification contributed to the event.

Implications:

• Highlights the need for robust communication protocols in pediatric procedural sedation and anesthesia.
• Emphasizes the importance of standardized medication verification processes.
• Underscores the potential for severe adverse events from local anesthetic systemic toxicity (LAST) in pediatric patients.