A Case of Brainstem Anesthesia after Retrobulbar Block for Globe Rupture Repair

Abstract

Purpose. To present a rare case of brainstem anesthesia from retrobulbar block and discuss evidence-based methods for reducing the incidence of this complication. Case. A 72-year-old female, was given a retrobulbar block of 5 mL of bupivacaine 0.5% for postoperative pain management, after a globe rupture repair under general anesthesia. Prior to injection, the patient was breathing spontaneously via the anesthesia machine circuit and had not received any additional narcotics/muscle relaxants for 2.5 hr (with full recovery of neuromuscular blocking agent after anesthetic reversal). Over 7 min, however, there was a steady increase in ETCO2 and the patient became apneic, consistent with brainstem anesthesia. She remained intubated and was transported to the postanesthesia care unit for prolonged monitoring, with eventual extubation. Discussion. Brainstem anesthesia is an important complication to recognize as it can lead to apnea and death. The judicious use of anesthetic volume, shorter needle tips, and mixed formulations can help reduce the chance of brainstem anesthesia. Observation of the contralateral eye 5–10 minutes after injection for pupillary dilation, and prior to surgical draping, can help identify early CNS involvement.

Globe penetration during loco-regional anesthesia: prevalence and review of cases

“…This type of anesthesia includes different sub-types, such as topical anesthesia [13][14][15] , subconjunctival anesthesia [16][17][18] , retrobulbar anesthesia, peribulbar anesthesia, sub-Tenon's anesthesia [9,[19][20] , medial canthus epiescleral anesthesia [21] and facial nerve block. Topical anesthesia has become a common form of anesthesia; however, it requires that the surgery is performed quickly and efficiently to minimize stress on the patients [22] , patient cooperation [23] , experienced surgeon [10] and it doesn't provide the same level of pain relief as peribulbar anesteshia [24][25] . We still prefer loco-regional anesthesia not only for posterior segment or glaucoma surgery but also because it is the preferred method for anterior segment surgery.…”

“…To avoid the necessity for general anesthesia in ocular surgery, blockage of the optic nerve using needle-based blocks is widely implemented to achieve akinesia and analgesia. Complications of the procedure (e.g., haemorrhage [4] , iatrogenic injection of the local anaesthetic into the opticnerve sheath [5] , penetration of the ocular glove [6] , amaurosis [7] , iatrogenic ophthalmic artery occlusion [8][9] or brainstem anaesthesia [10] ) are rare. Although these complications may be avoided with topical administration, loco-regional anesthesia is preferred in procedures requiring both akinesia and deep anesthesia.…”

Brainstem Anesthesia after Retrobulbar Anesthesia in Cataract Surgery: A Case Report

“…The second mechanism is a systemic absorption of the anesthetic product (venous/arterial). The third mechanism, the most commonly accepted and the one incriminated in our case, is the puncture of the dura mater which leads to a diffusion of the anesthetic product in the subarachnoid space, and consequently an accumulation of the product in the meninges [1], [2]. Studies on cadavers have confirmed this hypothesis of dye reaching the brainstem after intra-orbital subdural space puncture [2], [3].…”

“…The third mechanism, the most commonly accepted and the one incriminated in our case, is the puncture of the dura mater which leads to a diffusion of the anesthetic product in the subarachnoid space, and consequently an accumulation of the product in the meninges [1], [2]. Studies on cadavers have confirmed this hypothesis of dye reaching the brainstem after intra-orbital subdural space puncture [2], [3]. The latter is characterized by a latency between the injection of the product and the appearance of the signs because of the time necessary for the product to arrive at the level of the brainstem [2].…”

Vestibular Symptoms Following a Retrobulbar Block: A Case Report

“…1 Although the retrobulbar approach has a higher success rate, it is associated with a higher risk of complications when compared to peribulbar blocks, 2 such as brainstem anesthesia. 3 The administration of short-acting local anesthetics can cause rapid-onset and short-duration neurological changes, with full recovery after the block subsides.…”