Reactions 1151 - 12 May 2007

SBupivacaine

Coma following intrathecal administration in anelderly patient: case report

An 82-year-old woman developed coma after receivingbupivacaine for combined spinal-epidural anaesthesia [dosagenot clearly stated].

The woman was admitted with a right hip fracture and asurgery was planned using combined spinal-epiduralanaesthesia; before surgery, she had a normal neurologicalexamination and increased levels of blood urea (14 mmol/L)and creatinine (2620 µmol/L). After a needle insertion at herL2/3 interspace, she received 1.6mL of 0.5% bupivacaineintrathecally, and an epidural catheter was inserted. Aftersurgery, she received an epidural infusion of 0.125%bupivacaine at a rate of 5 mL/h. On postoperative day 2, shedeveloped agitation, confusion, dyspnoea and tachypnoea.She was transferred to an ICU.

The woman started receiving sulbactam/ampicillin for apresumed aspiration pneumonia. She also receivedhaloperidol for delirium and, on postoperative day 3, shedeveloped confusion. She then developed coma andunderwent endotracheal intubation on day 5. An MRI revealeda mass (5–6cm) in her left frontal lobe, which was suggestiveof a meningioma with diffused surrounding oedema, whichcaused central herniation. Oedema was treated andsubsequent MRI findings showed a meningioma with ahaemorrhagic component, along with a middle line shift anddiffused oedema. She showed no response to treatment anddied on postoperative day 18.

Author comment: "It was thought in this case that theintracranial pressure gradient after [combined spinal-epidural]anaesthesia caused herniation. . . [W]e want to remind othersof the possibility of an undiagnosed intracranial mass if thepatient’s mental status deteriorates after [combined spinal-epidural anaesthesia] ."Guner B, et al. Coma after combined spinal-epidural anaesthesia. British Journal ofAnaesthesia 98: 694-695, No. 5, May 2007 - Turkey 801071359

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Reactions 12 May 2007 No. 11510114-9954/10/1151-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved