RevBrasAnestesiol.2014;64(2):121---123
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
CLINICAL
INFORMATION
Total
spinal
block
after
lumbar
plexus
block:
a
case
report
Zafer
Dogan
∗,
Mefkur
Bakan,
Kadir
Idin,
Asim
Esen,
Fatma
Betul
Uslu,
Erdogan
Ozturk
DepartmentofAnesthesiologyandIntensiveCare,MedicalSchool,BezmialemVakifUniversity,Istanbul,Turkey
Received5December2012;accepted20March2013 Availableonline11October2013
KEYWORDS
Totalspinalblock;
Lumbarplexusblock;
Peripheralnerve block;
Monitorization; Totalknee replacement
Abstract Lumbarplexusblock(LPB)isasuitablemethodforelderpatientsforlowerextremity surgery.ManycomplicationscouldbeseenduringLPB,butnotasmanyascentralblock.Inthis casereport,weaimedtoreportatotalspinalblock,anunusualcomplication.LPBwithsciatic blockwasplannedforamalepatient,76yearsold,scheduledfortotalkneereplacementdue togonarthrosis.ThepatientbecameunconsciousafterpsoascompartmentblockwithChayen techniqueforLPB.Theoperationendedat145thminute.Thepatientwasadmittedtointensive careunituntilpostoperativeseconddayanddischargedtohomeonfifthdayofsurgery.Main concernofpatientmonitorizationshouldbeananesthesiologist.Inthismanner,weconclude thatcontactingtothepatientshouldbeensuredduringtheseprocedures.
© 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.
Lumbar plexus block (LPB) is a method of
intraopera-tiveanesthesia1,2andpost-operativeanalgesia3,4 forelder
patientswhohavepoorgeneralconditionoradditional dis-eases for lower extremity surgery. Firstly, this block was implementedbytheinguinal paravascularblocktechnique by Winnie5; it has been modified as psoas compartment
blockby Chayen.6 Variouscomplicationsmayoccur during
LPB,but notasmuchasthe centralblock. These include epidural block with double-sided spreading, hypotension, nausea and vomiting, local anesthetic toxicity, retroperi-tonealhematoma.7---9Inthiscasereport,weaimedtoreport
atotalspinalblock,anunusualcomplicationofLPB.10
∗Correspondingauthor.
E-mail:drzdogan@yahoo.com(Z.Dogan).
Case
Amalepatient,76yearsold,wasscheduledfortotalknee replacementduetogonarthrosis.Thepatienthadcoronary arterydisease,hypertension,andchronicrenalfailureand hadnohistoryofallergy,smokingandalcohol.Thepatient hadnohistoryof anesthesia, butoncehad local anesthe-siaforexcisionofbasalcellcarcinoma.Examinationofthe patient’s airway was Mallampati class II. He had crepita-tiononbasalofbothlungs.Preoperativebloodcount:Hgb: 12.0Htc:37.3,Plt:344,000,BUN:40,Creatinine:1.98,AST: 35,ALT:9,Na:138,K:4.7,Ca:9.9.Preoperative Cardiol-ogy,InternalmedicineandPulmonologyconsultationswere completed.
LPB(40cc)withsciaticblock(10cc)with50ccof%1 prilo-caineand%0.25bupivacainewereplannedduetopatient’s both heart and lung diseases. The patient wasmonitored
0104-0014/$–seefrontmatter©2013SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.
122 Z.Doganetal.
intheoperatingroom,withHR:60/bpm;TA:120/72mmHg andSpO2:94%.Thepatientwassedatedwith2mgof midazo-lam.Thepatientwasgivenoxygenbyfacemaskat4L/min. Aftersterilizationandcovering,L4---L5spinousprocessesand anteriorsuperioriliacspinewereidentified.Local anesthe-sia with %1 prilocaine was administered superficially and profoundly in point determined. After that, 10cm Stimu-plexneedle(1.5mAstimulus)wasinsertedatthespecified pointforpsoascompartmentblock.Verbalcommunication was maintained with the patient. Then quadriceps mus-clewasstimulated,and thestimuluswasturned downby 0.2mA.Afterstimulationfailureofthemusclewasseenat thelevelof0.5mAandaspiration,thelocalanesthetic solu-tionwasinjected. At thistimeverbalcommunicationand aspirationwere maintainedwith every5cc injection,the patientwasasked‘‘Are you OK,doyou haveany pain?’’. The drugwasgivenasa 40cc for LPBand thenwe asked againthe same question, but the patientsaid ‘‘Iam OK, butIhavesomenausea’’.Thereuponsciaticblockplanned was abandoned, the patient was laid in the supine posi-tionandvitalsignswerere-evaluated:HR:55---58/bpm,TA: 113/63mmHg,SpO2:100%.Next,weaskedthepatient‘‘are you OK?’’. While the patient said ‘‘I am fine’’ loudly up totwominutesofinjection,hesaid‘‘Iamfine butI can-not talk’’ with lip movements. Then the patient’s verbal responsewasclosedandeyeopeningresponsereceivedonly atapproximatelythirdminuteoftheinjection.Afterthat, noresponsehadbeenreceivedandthepatient’srespiration hadbecomeineffectiveatapproximatelyfifthminuteofthe injection.LMAinsertionwasdecidedandthen2mg midazo-lamwasadministered.AfterLMAinsertion,thepatientwas connectedtomechanicalventilator.Thepatient’svital find-ings were:HR: 53---62/m, TA: 115---93/78---56mmHg, SpO2: 98---100%.
Afterthesurgicalteamhadbeeninformedaboutthe sit-uation,thesurgicalprocedurewasallowed.Mixtureof50% oxygenand50%N2Owith%0.5---1sevofluranein4L/minfresh flow has been used for maintenance of anesthesia. Neu-romuscularblockeragentwasnot used.Approximately at the 50th minute of the skin incision(68th minute of the injection), cardiac rate lowered to 45, therefore 0.5mg atropinewasadministered.Therewerenootheranesthesia relatedproblems. Approximately at 130th minute of inci-sion (148th minute of injection), spontaneous respiration returned.The surgery wasended at145thminute of inci-sion(163rdminuteofinjection).Attheendoftheoperation, thepatient’stidalvolumewas300---450mL.LMA hadbeen taken off following the patient’s returning to conscious-ness,andthenthepatienthadbeentakentotherecovery unit.
2000cccrystalloidand1000cccolloidwereadministered tothepatientperioperatively.Patient’surinaryoutputwas approximately200ccattheendofsurgery.Thepatientwas confused,disorientatedandnon-cooperative.Inthe recov-eryunit,thepatientwasgivenonly4L/minoxygenbyfacial mask. The patientwasmonitored for 30min. The patient wasadmitted totheintensivecare unitbecausepatient’s SpO2 was lowered to 74% in room condition. Other vital findingswereTA:102/63mmHg,HR:64/bpm.
Aftertheoperation,thepatientwasgettingbetter.Inthe fifthhouraftertheoperation,thepatientwascompletely conscious, oriented, and cooperative. In the neurological
examination offifth hour aftertheoperation, thepatient had a diffuse loss of feeling. The muscle power was 5/5 ontheright upperextremity,while itwas4/5ontheleft upper extremity and there was a minimal tremor in the upper extremity. The muscle power was 3/5 onthe right lower extremity. The left side, operation side, could not be exactly evaluated. In the neurological examination of 24thhouraftertheoperation,althoughtheleftsidewasnot completelyevaluated,thepatientdidnothaveany abnor-mality regarding sensorialand motor activity.The tremor in theupper extremitywasdisappeared. The patientwas discharged fromthe ICU tothe orthopedics clinic. In the postoperative5thday,thepatientwasdischargedfromthe clinic.
Discussion
Peripheralnerveblockagecan bepreferredinthepatient thathaveadditionaldiseases,especiallycardiovascular dis-eases,and---orthepatientswhohavepoorgeneralcondition, becauseitdoesnotdestabilizethehemodynamicbalance.11
We planned to perform peripheral nerve blockage in our patientbecauseoftheaccompanyingdiseasesandthe phys-icalfindingoflungs.
Considering the events after the lumberplexus block-age by Chayen method, with the entire quick onset and symptoms,we assumed involuntaryspinal injection. How-ever itisnotablethatnoliquidhadbeenidentifiedinthe aspirationbeforetheinjection.Chayenetal.reportedonly one patient,whohada majorlumbardeformity,in a 100 patientseriesandhadcerebralspinalliquidaspirationand theynoticedandstoppedtheinjection.Inourpatient, nei-thertherewasliquidaspiration,nordidthepatienthavea lumbaranomaly.However,itisalsonotablethatourpatient didnothaveamajorhemodynamicinstability,but moder-atebradycardia.Hemodynamicstabilityof ourpatientdid notmakesenseregardingtotalspinalblockage.Ontheother hand,consideringthepatient’solderageandlimitedcardiac reserve, itisexpectedthatthepatientsmust beaffected moreseverely.Howeverintensive fluidresuscitationmight havepreventedtheexpectedhemodynamicinstability.
The patient has been evaluated for peripheral nerve blockage complications, including bilateral blockage by epiduralspreading,hypotension,nausea-vomitingandlocal anesthetictoxicity.
Spreadingthroughthespinalcordvia epiduralspace is possible.Insuchcondition,bilateralanesthesiaoccursand hemodynamic dataofthe patientmight bemoreseverely affected. But we did not think such a spreading in our patient,becausetheprogresswasveryfast.
Nauseain our patient maybe related tothe hypoten-sion or local anesthetic toxicity. If it was due to local anesthetictoxicity,metallictaste andtinnituswouldhave beenexpectedfirstly.Besidesthis,therewasnotprofound hypotensioninourpatient.Consideringtotalspinal block-age,itcanbethoughtthatnauseaoccurredbecauseofthe dominancyofvagalnerve.
TotalspinalblockafterLPB 123
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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