The Problem to a Solution: A Case of Local Anesthetic-Related Acute Pancreatitis

Although rare, local anesthetic use has been associated with adverse central nervous system and cardiovascular adverse events. One complication is local anesthetic systemic toxicity (LAST), wherein the anesthetic agent inadvertently enters systemic circulation resulting in widespread inhibition of fast-gated sodium channels. Organs dependent on aerobic metabolism, such as the heart and brain, are especially susceptible to toxic injury resulting in cardiovascular collapse. Lipid emulsion therapy is a mainstay treatment of LAST; however, it may inadvertently cause lipid-induced necrotizing pancreatitis. We present a 71-year-old female with a non-contributory past medical history who presented for elective open reduction and internal fixation (ORIF) of the right wrist after a fall onto the right hand one week prior. A supraclavicular brachial plexus block was planned to deliver regional analgesia for ORIF of the right wrist. Shortly after the introduction of the local anesthetic agent, our patient became bradycardic and hypotensive. The patient's heart rate and systolic blood pressure remained in the low 45s and 50s, respectively, refractory to multiple doses of phenylephrine and ephedrine. Suspicion for LAST syndrome was high and lipid emulsion therapy was started. Once stabilized, the patient was transported to the ICU requiring manual ventilation, where she later reported flank pain. Labs drawn were notable for elevated triglyceride, lipase, and amylase levels of over 3000, 600, and 700, respectively. CT imaging confirmed acute necrotizing pancreatitis. The patient's ICU stay was uncomplicated with stabilization of vitals and discharge 10 days later. A follow-up with gastroenterology (GI) was scheduled after two weeks. Since discharge, the patient noted intermittent abdominal aches. Magnetic resonance cholangiopancreatography (MRCP) and MRI were performed after liver function tests (LFTs) were found to be elevated during her follow-up appointment. MRI showed liquefaction necrosis of 80% of the pancreas, with a 14-centimeter fluid collection pushing on the distal common bile duct, causing extrinsic obstruction. MRCP revealed no stones. Advanced GI performed a transgastric cystogastrostomy with lumen apposing metal stent placement in the common bile duct, and drained the fluid from the obstructing cyst. Cytopathology came back as virtually acellular. Liver enzymes began to downtrend appropriately and the patient was discharged soon after. Follow-up at two and four days post-discharge confirmed resolution of symptoms.