Reactions 1268 - 5 Sep 2009

SBupivacaine

Inadvertent total spinal anaesthesia afterintercostal nerve block in an elderly patient: casereport

A 66-year-old man developed inadvertent total spinalanaesthesia after intercostal nerve block placement withbupivacaine during lung resection.

The man, who had suspected non-small cell lung cancer,was scheduled for lung resection. He received temazepamas premedication and anaesthesia induction with isofluraneand vecuronium bromide; he was intubated. An epiduralcatheter was placed and 0.5% bupivacaine 4mL wasadministered. Anaesthesia was maintained withremifentanil, isoflurane and vecuronium. The lobectomywas performed and intercostal nerve blocks with 0.5%bupivacaine were placed under direct vision; a total of10mL was placed below the heads of the third to seventhribs, raising visible blebs. Care was taken to aspirate backto avoid intravascular injection; no blood or cerebrospinalfluid was aspirated. His systolic BP subsequently decreasedto 60mm Hg [time to reaction onset not clearly stated].

The man received metaraminol and his anaesthesia wasstopped. The neuromuscular blockade was reversed withglycopyrrolate and neostigmine. Examination showeddilated, fixed pupils and complete paralysis, with norespiratory effort. He failed to awaken and he wastransferred to the ICU with suspected stroke or total spinalanaesthesia. Respiratory effort had not returned 1 hourafter leaving the operating theatre, so he requiredcontinuous mechanical ventilation. His BP remained low,requiring colloid infusions and norepinephrine[noradrenaline]. He improved in a stepwise fashion. Hebegan to make ventilatory effort, his pupils normalised insize and became reactive, and he woke up. Motor powergradually returned craniocaudally over a 2-hour period.Twelve hours after leaving the operating theatre, all hisneurological deficits had resolved and he was extubated. Afull recovery was confirmed and an epidural infusion of0.1% bupivacaine was started and continued for 3 days.

Author comment: "The mechanism behind theseobservations is possible inadvertent injection into a dural cuffextending beyond the intervertebral foramen."Chaudhri BB, et al. Inadvertent total spinal anesthesia after intercostal nerve blockplacement during lung resection. Annals of Thoracic Surgery 88: 283-284, No. 1,Jul 2009 - Scotland 801150195

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Reactions 5 Sep 2009 No. 12680114-9954/10/1268-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved