Case Report Ropivacaine Plasma Concentrations after 192-Hour High Dose Epidural Ropivacaine Infusion in a Pediatric Patient without Side Effects Glenn van de Vossenberg , 1 Selina van der Wal, 1 Andrea Müller, 1 Edward Tan, 2 and Kris Vissers 1 1 Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, Netherlands 2 Department of Surgery, Radboudumc, Netherlands Correspondence should be addressed to Glenn van de Vossenberg; glenn.vandevossenberg@radboudumc.nl Received 23 January 2018; Accepted 1 July 2018; Published 11 July 2018 Academic Editor: Anjan Trikha Copyright © 2018 Glenn van de Vossenberg et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Tis case report discusses continuous epidural administration of ropivacaine 0.56 mg kg -1 h -1 for 8 days in a 7-year-old trauma patient to prevent pain, afer performing a lower right and upper lef leg guillotine amputation. Venous sampling afer 8 days revealed bound and unbound ropivacaine concentrations of 1.1 mg/l and 0.06 mg/l in plasma, respectively. Arterial sampling for bound and unbound ropivacaine was 1.2 mg/l and 0.05 mg/l in plasma, respectively. In this case report, long-term high dose epidural infltration of ropivacaine did not result in severe side efects or complications. Further studies are needed to explore safety of these concentrations in larger populations of children. 1. Introduction Since cocaine was introduced in the 19 th century by Carl K¨ oller and Sigmund Freud, the use of local anesthetics (LA) has evolved enormously. Local anesthetics can be used to pro- duce local, locoregional, and neuraxial nerve blockade. Bind- ing of LA to various subtypes of sodium channels (Na v ) in the nervous system produces nerve blockade. Currently 7 sub- types of Na v are known in the nervous system. Blocking on these receptors can potentially cause minor side efects such as a metallic taste or tingling, but also severe side efects such as seizures and cardiac arrest. All these symptoms and adverse efects are referred to as local anesthetic systemic toxicity (LAST) [1]. In pediatrics little is known about the absolute maximum dosages for epidural infusion of ropivacaine. Only two studies [2, 3] have been performed in pediatrics assessing the save use of ropivacaine given via continuous epidural infusion for maximum dose of 0.4 mg kg -1 h -1 . In this case report we present and discuss a case of continuous adminis- tration of ropivacaine 0.56 mg kg -1 h -1 in the epidural space for over 8 days to control severe pain afer bilateral ampu- tation and reveal its concentration in venous and arterial plasma afer 8 days. Written informed consent was obtained from the patient’s parent for publication of this report. 2. Clinical Presentation A previously healthy 7-year-old male presented to a com- munity hospital with severe lower extremity trauma due to accident with a truck. Te patient was instantly brought to the OR and the surgeon performed a lower right leg and an upper lef leg guillotine amputation. During surgery the patient received one litre of crystalloids, two units of packed cells, and one unit plasma and remained hemodynamically stable with low noradrenaline dosage. For postoperative analgesia a n. ischiadicus and a n. popliteal catheter were placed during surgery in the lef and right lower extremity, respectively. Since much postoperative pain was expected ropivacaine infusion of 0.2 mg kg -1 h -1 was started over each catheters (0.4 mg kg -1 h -1 in total), postoperatively. Intravenous infusion of esketamin 0,2 mg kg -1 h -1 and morphine 20 mcg kg -1 h -1 was started additionally. Initially peripheral catheters were preferred since less hemodynamic Hindawi Case Reports in Anesthesiology Volume 2018, Article ID 9150980, 3 pages https://doi.org/10.1155/2018/9150980