Sudden neonatal death following circumcision associated with bupivacaine-induced Local Anesthetic Systemic Toxicity (LAST): a forensic case report.

This article presents a fatal case of local anesthetic systemic toxicity (LAST) in a healthy 26-day-old male following a ritual circumcision. Bupivacaine, a local anesthetic, was used to induce a dorsal penile nerve block and a ring block. No other medications were administered. Postoperatively, the mother noticed the neonate had become sleepy. She allowed him to rest, assuming he was asleep. Two hours later, she attempted to awaken him but found him dead. Postmortem examination revealed a circumcised penis with a localized hematoma, suggesting inadvertent vascular injection of bupivacaine. Dissection revealed generalized cerebral edema and focal subarachnoid hemorrhage. Histopathological assessment of brain tissue revealed perineuronal vacuolations in the brain cortex consistent with cerebral edema. The watershed region demonstrated perivascular hemorrhage, associated with spongiosis and vacuolation of the neuropil, and focal neutrophilic perivascular infiltrates. Histological sections of the leptomeninges revealed focal subarachnoid hemorrhage with erythrocyte extravasation and inflammatory cell infiltration. Regarding toxicological analysis, the bupivacaine concentration in peripheral blood was 5 µg/mL. A thorough post-mortem examination did not reveal signs of pathology or trauma. The cause of death was assumed to be LAST, based on the temporal association between the death and the circumcision performed under this local anesthetic, the detection of bupivacaine in blood, and the pathological findings. While there are no pathognomonic pathological features of LAST, the pathological results may align with hypoxic-ischemic brain injury. Severe hypoxia could develop in bupivacaine systemic toxicity due to direct inhibition of the respiratory center or to fatal arrhythmia and cerebral hypoperfusion. KEY POINTS: • This article presents a case of fatal bupivacaine toxicity in a neonate following circumcision. • Postmortem examination revealed a circumcised penis with a localized hematoma. • Pathological examination revealed cerebral edema, inflammatory reaction, and focal subarachnoid hemorrhage. • Bupivacaine was detected in peripheral blood at a concentration of 5 µg/mL. • The pathological findings suggest hypoxic-ischemic brain injury due to bupivacaine toxicity.