Ann Thorac Surg 2009;88:283-284. doi:10.1016/j.athoracsur.2008.09.070
© 2009 The Society of Thoracic Surgeons
Case Reports
Inadvertent Total Spinal Anesthesia After Intercostal Nerve Block Placement During Lung Resection
Babar B. Chaudhri, FRCSa,*,
Alistair Macfie, FRCAb,
Alan J. Kirk, FRCSb
a Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
b West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
Accepted for publication September 29, 2008.
* Address correspondence to Dr Chaudhri, Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Little France Cr, Edinburgh, EH16 4SA, United Kingdom (Email: bchaudhri{at}mac.com).
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Abstract
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Intercostal nerve block is a recognized way of providing analgesia at thoracotomy. There is a rare association between intercostal nerve block and the complication of total spinal anesthesia. This may arise inadvertently by injection into a dural cuff extending outside the intervertebral foramen. We report our experience with a patient who sustained this life-threatening complication. The patient required postoperative ventilation until the neurologic deficits resolved. The operator must be aware that intercostal nerve block runs the rare but potentially fatal risk of total spinal block.
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Introduction
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Dissemination of local anaesthetic agent is possible from the site of injection away from its intended target and may result in serious complications [1, 2]. We report a case of total spinal anesthesia after placement of intrathoracic intercostal nerve blocks at the time of lung resection.
A 66-year-old man was scheduled for left thoracotomy and anatomic lung resection for a left lower lobe mass that was highly suspicious of non-small cell lung cancer (NSCLC). A computed tomography (CT) scan of the chest showed a 2- x 2-cm mass in the periphery of the left lower lobe. There was no evidence of mediastinal lymphadenopathy. A CT scan of the upper abdomen was unremarkable, and a CT scan of the brain showed no intracerebral lesions. The patient's forced expiratory volume in 1 second was 2.1 L and forced vital capacity was 2.8 L. There was no significant past medical history.
Temazepam was given as premedication, and anesthesia was induced with isoflurane and vecuronium. Intubation was performed with a medium-sized, right-sided Robertshaw double-lumen tube. An epidural catheter was placed, and 4 mL of 0.5% bupivacaine was administered before induction. Anesthesia was maintained with isoflurane, remifentanil, and vecuronium.
Surgical entry into the chest was by a standard left thoracotomy through the bed of the fifth rib. The serratus anterior was preserved in the incision. A biopsy for frozen section pathology analysis of the mass confirmed NSCLC, and a lower lobectomy was performed.
Intercostal nerve blocks with 0.5% bupivacaine were then placed under direct vision. No blood or cerebrospinal fluid (CSF) was aspirated at the time of injection. A total of 10 mL was placed below the heads of the third to seventh ribs, raising visible blebs. Care was taken to aspirate back, avoiding intravascular injection of bupivacaine. This was done without any apparent problem.
Two chest tubes were placed and the thoracotomy was closed. At this point the systolic blood pressure had fallen to 60 mm Hg without blood loss into the chest tubes. This was treated with intravenous metaraminol. The anaesthetic was discontinued. The neuromuscular blockade was reversed with neostigmine and glycopyrrolate, and this was confirmed using a peripheral nerve stimulator. The double-lumen tube was changed to a single-lumen endotracheal tube.
Clinical examination revealed fixed and dilated pupils, complete paralysis, and no respiratory effort was being made. The patient failed to awaken. There were no seizures. The patient was transferred to the intensive care unit with a putative diagnosis of either a global or brain stem stroke, or total spinal anesthesia. Propofol at 100 mg/h was commenced to avoid awareness and distress. Respiratory effort had still not returned at 1 hour after leaving the operating theater, so continuous mandatory mechanical ventilation was continued. The blood pressure was low, requiring colloid infusions and noradrenaline to maintain it above a systolic level of 100 mm Hg.
Gradually, the patient improved in a stepwise manner. He began to make ventilatory effort, and his pupils normalized in size and became reactive. The patient woke up. Motor power gradually returned craniocaudally (ie, face, upper limbs, lower limbs) during a 2-hour period. By 12 hours after leaving the operating theater, all neurologic deficits had resolved, and the patient was extubated. After full recovery was confirmed, the epidural infusion of 0.1% bupivacaine was commenced and continued for 3 days.
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Comment
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At thoracotomy, direct injection of local anaesthetic in the form of intercostal blocks or by catheters is generally without complications and results in good analgesia as a part of a multimodal approach to postoperative analgesia [3]. Our practice is to use epidural analgesia with a combination of nonsteroidal anti-inflammatory drugs and intercostal blocks. When epidural placement is not possible, this is substituted by opiate analgesia, usually by continuous or patient-controlled infusions. Subarachnoid spread after intercostals nerve block is a rare but life-threatening complication. The diagnosis is problematic in the unconscious patient, such as described here.
Other authors have reported total spinal block after intercostal block by direct injection at thoracotomy [4, 5] and subsequent subarachnoid spread. Lekhak and colleagues [6] reported total spinal block after placement of a paravertebral catheter. The mechanism behind these observations is possible inadvertent injection into a dural cuff extending beyond the intervertebral foramen. A negative aspiration of blood or CSF at time of intercostal block placement is not always reliable, and subarachnoid injection is possible despite this precautionary maneuver.
This case illustrates that placement of intercostal blocks is not without complication and that total spinal block may occur unexpectedly. This emphasizes the need for operator awareness of this complication and the importance of understanding the anatomy. Aspiration should be done at the time of intercostal block placement in an attempt to exclude CSF or blood. This test is not fail-safe, however. The surgeon should consider positioning intercostal blocks a couple of centimeters lateral to the head of the rib. This would ensure that a dural sac, which is protruding beyond the intervertebral foramen, is not penetrated.
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References
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- Gay GR, Evans JA. Total spinal anesthesia following lumbar paravertebral block: a potentially lethal complication Anesth Analg 1971;50:344-348.[Free Full Text]
- Adriani J, Parmley J, Ochsner A. Fatalities and complications after attempts at stellate ganglion block Surgery 1952;32:615-619.[Medline]
- Sabanathan S, Mearns AJ, Bickford Smith PJ, et al. Efficacy of continuous extrapleural intercostal nerve block on post-thoracotomy pain and pulmonary mechanics Br J Surg 1990;77:221-225.[Medline]
- Sury MR, Bingham RM. Accidental spinal anaesthesia following intrathoracic intercostal nerve blockade. A case report. Anaesthesia 1986;41:401-403.[Medline]
- Benumof JL, Semenza J. Total spinal anesthesia following intrathoracic intercostal nerve blocks Anesthesiology 1975;43:124-125.[Medline]
- Lekhak B, Bartley C, Conacher ID, Nouraei SM. Total spinal anaesthesia in association with insertion of a paravertebral catheter Br J Anaesth 2001;86:280-282.[Abstract/Free Full Text]
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Abstract
Introduction
