Third-Degree Heart Block Associated with Bupivacaine Infusion Following Total Knee Arthroplasty

Abstract

Total knee arthroplasty is one of the most successful operations performed. Multiple modalities are utilized for pain management in the perioperative period. Regional anesthesia is a common, effective method associated with high patient satisfaction. It typically provides exceptional local pain control without the systemic side effects that have been associated with oral or parenteral narcotics. Alleviation of pain allows for earlier mobilization and potentially shorter hospital stays. However, continuous infusion of a long-acting local anesthetic is not without risk. Case reports of severe complications such as hypotension, arrhythmia, seizure, and cardiovascular collapse have been reported, but all involved intra-articular injections or a single injection of a large dose of anesthetic medication to attain a regional block1-6. We found no reports of arrhythmia in association with an indwelling catheter in patients who were receiving regional anesthesia. We present the case of a patient in whom a third-degree heart block developed in association with a continuous bupivacaine infusion through an indwelling femoral catheter. The patient was informed that data concerning the case would be submitted for publication, and she consented. ### History A seventy-eight-year-old woman who weighed 59 kg had a five-year history of progressive, debilitating, left knee pain that was most severe with walking, stair-climbing, and arising from a seated position. As nonoperative treatment had failed to provide relief, the decision was made to perform a total knee replacement. Her medical history included osteoarthritis of both knees, peptic ulcer disease, a cerebrovascular accident in 1993, and cirrhosis of the liver secondary to alcohol abuse. The patient had previously undergone a right total knee arthroplasty with no complications. Physical examination of the left lower extremity demonstrated a 20° valgus deformity and an arc of knee motion from 15° to 115°. Due to the known fact that the patient had liver …