Antidote Worse Than the Poison? Emergent Therapeutic Plasma Exchange After Overzealous Intravenous Lipid Emulsion Infusion During Treatment of Local Anesthetic Systemic Toxicity

This case report describes therapeutic plasma exchange as treatment for a rare instance of severe hypertriglyceridemia following high-dose intravenous lipid emulsion (ILE) therapy for bupivacaine-induced local anesthetic systemic toxicity (LAST). The patient received a cumulative ILE dose of 28.0 mL/kg to control seizures, exceeding the typical recommended maximum dose of 10 mL/kg. Clinical presentation included severe headache, visual disturbances, and photophobia, concerning for hyperviscosity syndrome. Laboratory findings revealed a markedly elevated serum triglyceride concentration (> 10 350 mg/dL). Therapeutic plasma exchange with plasma was successfully employed to rapidly reduce serum triglycerides and alleviate symptoms. This case highlights the potential for severe iatrogenic hypertriglyceridemia associated with high-dose ILE therapy for LAST and emphasizes the importance of close clinical monitoring and timely intervention.