A very high block

Started by Iain Stowe, December 08, 2004, 10:49:35 AM

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Iain Stowe

I was doing a interscalene block for a shoulder replacement. Using a Stimplex needle, got good twitches at 0.5mA, nil on aspiration, and started injecting my bupivacaine 0.5%. Very quickly, and without warning (at about 5 mL) the patient groans, and falls unconscious. Thinking its just a faint, I place her flat, oxygen and waited. She didn't come around. In fact, she didn't breath. Her BP was low, pulse 40, apneic. Iintubated without using any drugs, and waited. And waited. And waited. BP and pulse improved quickly, but still apneic at 10 minutes.

My impression is I gave her a very high epidural or even a subarachnoid block, my needle being a bit deeper than I thought! Any other thoughts?

PS she woke up an hour later in ICU, remembers nothing of the incident, and wondered why her shoulder wasn't fixed!

Geoffrey Parkins

That the subarachnoid space "herniates" through the nerve root foramina is well known. It is surprisingly easy to access the subarachnoid space at the level of the neck, especially in the thin patient. I am pretty sure this is what happened.

An intravascualr injection (carotid or vertebral) would cause an instant seizure followed by a relatively short coma.

gasman

Where I come from (Canberra, Australia) there has been a definite shift away from regional techniques, and epidurals in particular.

Litigation is on the increase in this country, and politicians are very slow in legal reform. Given the small but definite risks of regional techniques (such as the one described above) and the fact that GA's are so safe with an excellent track record, its no wonder.

Petra Mensari

My surgeon is a very keen user of the Pain-Buster local anesthetic infusion system that infiltrates the wound with LA for 24 hours post op. It is placed by the surgeon, is risk-free and easly removed by nursing staff, or even the patient him/herself if they have gone home before 24 hours.

Since this was introduced, I have not done an interscalene block.

Bucky


An associate had a similar interscalene block experience with no untoward long term effects.  Probably was an intrathecal installation as described here by Dr Parkins.

One of our anesthesiologists introduced us to a cocktail which is instilled into the shoulder joint at the completion of shoulder surgery.  We have won over only one of our orthopods 100% so far, but since he has started using this mixture, we've not had to give any of his patients an interscalene block for post-op pain.

Cocktail:

30 ml 0.5% ropivacaine
+ 20 ml 2% lidocaine w/ epi
+ 50 mg meperidine


Sandy Hancock

A suprascapular nerve block combined with a superficial cervical plexus block can provide equivalent analgesia with *much* less risk. I can no longer justify interscalene blocks for post-operative analgesia.