[Ropivacaine-induced late-onset systemic toxicity after transversus abdominis plane block under general anesthesia: successful reversal with 20% lipid emulsion].

We report a case of late-onset systemic toxicity due to ropivacaine over dose, and its successful reversal with 20% lipid emulsion (20% Intralipos). A 40-year-old woman, 40 kg, ASA-I, was scheduled for laparoscopy-assisted myomectomy of the uterus in which 40 ml of 0.375% ropivacaine was injected for bilateral US guided transversus abdominis plane block (TAPblock) under general anesthesia. Anesthesia proceeded uneventfully and she could go back to the ward 15 min later, but 3 hours after TAPblock, her blood pressure dropped to seventies and she became unresponsive. She also displayed clonic seizure/twitching of limbs. Immediately after diazepam 2 mg injection, clonic seizure disappeared and she could obey verbal commands. Within a few minutes clonic seizure was noted again, and she was hypotensive despite administration of vasopressors. A presumptive diagnosis of local anesthetic toxicity was made, and she received 100 ml bolus of 20% Intralipos. She regained consciousness with spontaneous return of blood pressure. She received a total of 230 ml 20% Intralipos, which was discontinued due to her rapid emergence with no further seizure episodes. This case suggests that early and sufficient use of lipid emulsion may lead to a good outcome. We recommend the immediate availability of lipid emulsion along with other emergency therapeutics at the ward after TAPblock.