Refractory cardiac arrest due to inadvertent intravenous injection of 0.25% bupivacaine used for local infiltration anesthesia

The cardiotoxic effect of bupivacaine is a well-known fact that can lead to asystole, and most of the time it is refractory to resuscitative measures. We describe the case of a three-year-old child operated for anorectal malformation (ARM) by abdominal approach. Apart from congenital anomalies, preoperative evaluation was unremarkable. General anesthesia and controlled ventilation were instituted through endotracheal tube (ET). She had an uneventful intraoperative period. Immediately after surgery when local infiltration block was given using 0.25% of bupivacaine (6 ml volume) around the abdominal incision for postoperative analgesia, the patient went into cardiac asystole. Cardiopulmonary resuscitation (CPR) was continued for 60 minutes but the patient could not be revived. At that time we had neither lipid emulsion nor the facility for cardiopulmonary bypass in our hospital setup.