Inadvertent Total Spinal Anesthesia After Intercostal Nerve Block Placement During Lung Resection

doi:10.1016/j.athoracsur.2008.09.070

The Annals of Thoracic Surgery

Volume 88, Issue 1, July 2009, Pages 283-284

https://doi.org/10.1016/j.athoracsur.2008.09.070 Get rights and content

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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Comment

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.

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J. Adriani et al.
Fatalities and complications after attempts at stellate ganglion block
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Cited by (16)

Postoperative pain management: Truncal blocks in thoracic surgery
2021, Features and Assessments of Pain, Anesthesia, and Analgesia
Providing efficient analgesia after thoracic surgery is important as postoperative complications delay hospital discharge and are associated with mortality and morbidity. Thoracic surgery patients mostly have pulmonary diseases or due to the surgical site have altered lung functions.
Multimodal analgesia techniques are gaining popularity as reduction in systematically applied drugs are aimed. Ultrasound-guided interventions enables less complications with more precise injection of the local anesthetic drugs to desired locations resulting in more efficient pain relief. Truncal blocks effectively block the nerves and provide localized pain relief thus reduce the usage of opioids. The optimal dosage and concentration of the drugs used in truncal blocks are still investigated. This chapter gives information about the commonly used truncal blocks in thoracic surgeries.
Delayed emergence after anesthesia
2015, Journal of Clinical Anesthesia
Citation Excerpt :
Another possibility for delayed emergence with neurological symptoms such as paralysis is total spinal anesthesia. There are reports where patients were hypotensive, slow to wake up, showed complete paralysis and little to no breathing effort [54,55] after thoracic procedures. Chaudri et al [54] report a patient that failed to wake up after thoracotomy and had fixed and dilated pupils, complete paralysis, and made no respiratory effort.
In most instances, delayed emergence from anesthesia is attributed to residual anesthetic or analgesic medications. However, delayed emergence can be secondary to unusual causes and present diagnostic dilemmas. Data from clinical studies is scarce and most available published material is comprised of case reports. In this review, we summarize and discuss less common and difficult to diagnose reasons for delayed emergence and present cases from our own experience or reference published case reports/case series. The goal is to draw attention to less common reasons for delayed emergence, identify patient populations that are potentially at risk and to help anesthesiologists identifying a possible cause why their patient is slow to wake up.
Intercostal Nerve Block
2011, Pain Management, Second Edition
Truncal blocks: intercostal, paravertebral, interpleural, suprascapular, ilioinguinal, and iliohypogastric nerve blocks
2011, Essentials of Pain Medicine
Pain relief with paravertebral blocks or epidural analgesia? Those who do not know the history of paravertebral blocks are condemned to rediscover the complications
2010, Scandinavian Journal of Pain
A systematic review of comparative studies indicates that paravertebral block is neither superior nor safer than epidural analgesia for pain after thoracotomy
2010, Scandinavian Journal of Pain
The “gold standard” for pain relief after thoracotomy has been thoracic epidural analgesia (TEA). The studies comparing TEA with paravertebral block (PVB) and recent reviews recommend PVB as a novel, safer method than TEA.
A systematic search of the Cochrane and PubMed databases for prospective, randomized trials (RCTs) comparing TEA and PVB for post-thoracotomy analgesia was done. We assessed how TEA and PVB were performed, methods of randomization, assessment of pain relief, and complications. Abstracts only were excluded.
Ten studies were included, comprising 224 patients randomized to TEA, 243 to PVB. The studies were heterogeneous. Therefore, a systematic narrative review with our evaluations is presented.
Only 3/10 trials reported the method of randomization. Pain during coughing was reported in only 5/10, pain assessment not specified in 5/10. Only 1/10 trials found PVB superior to TEA, but placed TEA catheters too low (<T7). TEA was superior to PVB in 1/10, during first 1.5 days. PVB and TEA were equally effective in 8/10. 5/10 trials found PVB had less hypotension or urinary retention. None of the studies used appropriate and optimal TEA: TEA was started after end of surgery in half, catheters placed too low (2/10), too high (1/10), not reported in (1/10). 7/10 infused local anaesthetic only, 2/10 added fentanyl, 1/10 added morphine, and none added adrenaline. PVB infusions had higher concentration of bupivacaine (5 mg/ml) in 2/10, 1/10 added fentanyl, 1/10 added ornipressin. Loading doses were higher in 5/10, and with more concentrated solutions in 5/10 of PVB than in the TEA group.
10 heterogeneous, mostly small, studies comparing TEA and PVB for post-thoracotomy analgesia do not allow conclusions on which method has superior analgesic efficacy and safety. The main methodological problem was that none of the studies use optimal thoracic epidural analgesia, with siting of catheters inappropriate in some and the epidural infusion containing too concentrated local anaesthetic because opioid and adrenaline were not added. Anatomical considerations (the paravertebral space comprises parts of the epidural space and contains spinal cord arteries) and personally experienced complications with PVB (paraplegia) convince us that PVB must have higher risk of, infrequent but serious, spinal cord complications than TEA. Percutaneous PVB may puncture pleura and lung.
Some surgeons expressed satisfaction with PVB because the method omits costly acute pain services for monitoring on surgical wards and saves time in the operating room. They are, however, bound to experience serious complications from PVB, sooner or later.
To our knowledge, optimally conducted epidural analgesia has not been compared with PVB. Current literature and our experience with both techniques for up to four decades, indicate that PVB may be an alternative for post-thoracotomy pain when TEA is infeasible for various patient-related reasons (Breivik et al., 2009). Severely disturbed haemostasis is a contraindication for PVB and TEA. Higher concentrations of local anaesthetics are needed to obtain intercostal nerve blocks and epidural analgesia with PVB, risking local anaesthetic intoxication. Robust monitoring regimen for effects and adverse effects is as important for PVB as for TEA.

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Case reportInadvertent Total Spinal Anesthesia After Intercostal Nerve Block Placement During Lung Resection

Section snippets

Comment

Br J Anaesth

Total spinal anesthesia following lumbar paravertebral block: a potentially lethal complication

Anesth Analg

Fatalities and complications after attempts at stellate ganglion block

Surgery

Case report
Inadvertent Total Spinal Anesthesia After Intercostal Nerve Block Placement During Lung Resection