![]() The rest of the procedure was unremarkable. Sciatic blockade proved insufficient we had to induce general anesthesia with 300 mg pentothal, 75 mg succinylcholine, 150 mg fentanyl. After discussion with the surgeon in charge, we decided to proceed with the scheduled operation. We decided not to perform any femoral block as previously planned to improve comfort during tourniquet inflation. Testing for superficial sensation to cold using a cold pack confirmed presence of an efficient sciatic block despite normalization of both neurologic and cardiac functions. Measured levels were1.9 mg/l (6.94 μmol/l) and 1.4 mg/l (5.02 μmol/l) respectively. We monitored ropivacain blood levels with samples drawn 20 and 50 minutes after local anesthetic injection. Instead, a second lipid emulsion was kept ready for infusion in case of recurring symptoms of local anesthetic toxicity. The patient remained monitored for about 30 minutes in the anesthetic area we observed no recurring signs of local anesthetic intoxication and therefore decided to forfeit the recommended lipid infusion maintenance dose. After initial management, hemodynamics and cardiac electrical activity remained stable without need for further support. Confusion regressed quickly within 5 minutes her neurologic and mental status returned to baseline. We immediately administered pure oxygen by facemask, injected 100 mcg phenylephrine intravenously, and started a 100 ml single bolus of 20% lipid emulsion over approximately 1 minute. Blood pressure concomitantly dropped to 70/40 mmHg while heart rate accelerated to 96 bpm. The patient never lost consciousness she remained aware of her surroundings at all times and could describe her visions of climbing a very steep mountain with great precision. Within seconds after injection of the local anesthetic solution (while the patient was being repositioned supine for femoral nerve blockade), we observed sudden clonic movements of the limb, followed by profound confusion and visual hallucinations. After absence of blood on inspiration was confirmed, 20 ml of 0.5% ropivacain were injected over 2 minutes with repeated aspiration tests at 5 ml intervals. Appropriate foot flexion was elicited within one minute and current intensity was reduced until disappearance of motor response at 0.3 mA. Braun Melsungen AG, Melsungen, Germany) with a starting output of 1 mA, 1 ms and 2 Hz. A 100 mm insulated needle (Top Neuropole needle-ST, 100 mm 23G, Top corporation, Tokyo, Japan) was connected to a nerve stimulator (Stimuplex HNS 12, B. Labat’s approach was used for sciatic blockade. Before the patient was positioned on the right side, 50mcg fentanyl was administered intravenously to maximize the patient’s comfort during performance of regional anesthesia. Baseline blood pressure was 120/60 mmHg, pulse 70 bpm, pulsed oxymetry 96% at ambient air. ![]() A 1000 ml Lactated Ringer infusion was started. Shortly after arrival in the anesthetic area, standard monitoring with a 3-lead continuous ECG, blood pressure cuff on right arm, and pulsed oxymetry was installed in addition to placement of a 20G intravenous catheter on the left forearm. Anesthetic risk was graded American Society of Anesthesiologists (ASA) 2 due to a personal history of left breast cancer surgically removed by tumorectomy, and a regressive cerebral vascular accident for which she was prescribed aspirin.ħ.5 mg oral midazolam was administered before the procedure. This is a 67 year old woman, 160 cm tall and weighing 52 kg, who was scheduled for left foot arthrodesis. Informed consent was obtained from the patient for publication of this case report. In absence of further signs of toxicity, the continuous intralipid infusion was interrupted. Subsequently she remained hemodynamically stable and her neurological status returned to baseline. Prompt infusion of a 100 ml intralipid emulsion in addition to a single bolus of 100 mcg phenylephrine reversed these signs within less than five minutes. A 67 year old female patient presented with new neurological deficits (clonic movements, progressive confusion, dysarthria) and hemodynamic instability (hypotension, sinus tachycardia) immediately after uneventful performance of a sciatic block. ![]()
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |