Iatrogenic Intrapleural Lidocaine Toxicity With Prolonged Neurologic Effects: A Case Report

A 63-year-old male with a history of chronic obstructive pulmonary disease was admitted for management of spontaneous pneumothorax with talc pleurodesis. Prior to the procedure, lidocaine local analgesia was administered via a thoracostomy tube that had been previously placed. Due to a dosing error, lidocaine 1% (without epinephrine) was inadvertently administered at 3 mL/kg instead of 3 mg/kg, resulting in an administration of 180 mL (1800 mg, or approximately 29 mg/kg) of drug—a 10-fold overdose—over 1 min. The patient became rapidly obtunded and then unresponsive but maintained oxygenation and cardiac output. Thoracic lavage with normal saline was performed to decontaminate the pleural space, and 20% lipid emulsion was administered with a total dose of 600 mL (~10 mL/kg). Mental status normalized 24 h later. This case highlights the rapidity with which lidocaine administered via an intrapleural route, when excessively dosed, may lead to systemic toxicity, possibly due to high pleural absorptive capacity. Clinicians should adhere to recommended dosing limits when administering intrapleural lidocaine and consider thoracic lavage and aspiration in cases of iatrogenic toxicity.