Catastrophic complication of an interscalene catheter for continuous peripheral nerve block analgesia

Abstract

Summary We report a catastrophic postoperative complication of a prolonged interscalene block performed under general anaesthesia. The course of the anaesthetic was uneventful and the patient remained stable during his stay in the recovery area with the operative extremity paralysed and insensate. No further local anaesthetic was administered until later that day when the patient received 10 ml bupivacaine 0.25% through the catheter. Upon completion of the top‐up dose, no change in the patient’s status was noticed. The patient was next assessed 6.5 h later when he was found dead in his bed. A postmortem CT scan revealed the catheter to be sited intrathecally, presumably the result of dural sleeve penetration.

A Review of Local Anesthetic Systemic Toxicity Cases Since Publication of the American Society of Regional Anesthesia Recommendations

“…Fifty cases of toxicity occurred after a single injection of LA, whereas in 8 cases, signs and symptoms arose during continuous infusion of LA. 35,38,40,41,54,55,58 In 7 cases, toxicity followed topical administration of LA without needle injection. 26,45,47,48,50,57,59 Finally, in 2 cases, LAST followed direct unintentional LA intravascular injection through a venous cannula.…”

“…[8][9][10][12][13][14][15][16][17][18][19][20][21][22]24,25,[27][28][29][31][32][33][34][36][37][38][40][41][42][43][51][52][53][54][55][56][57][58]60,61 Twelve percent of the cases developed in an office, 30,39,45,46,[48][49][50] whereas another 4% occurred in other locations, including the patient's home. Finally, 15% of the authors did not specify the hospital setting where the LA was administered.…”

“…Eleven (16%) cases reported the use of UGRA. 19,25,29,32,33,35,51,53,55 Fifteen (22%) practitioners adopted ENS, 12,16,22,24,29,31,41,44 whereas intermittent aspiration before injection was reported in 22 cases of LA administration for peripheral nerve block. 8,11,15,16,18,19,22,24,25,27,[31][32][33]36,38,41,43,46,58 Finally, only 1 author reported on the concomitant use of ultrasound, ENS, and intermittent aspiration 29 in a patient who developed toxicity 10 minutes after LA injection.…”

Ultrasound-Guided Interscalene Block

“…We have not failed to notice 30 that such a bifurcation provides an entrance path into the neuraxis and could help explain some catastrophic outcomes associated with interscalene blocks. [31][32][33][34][35] The spread into the neuraxial space from an interscalene injection has been usually explained as an injection within the dural sleeve of a spinal nerve. However, because this sleeve rarely extends beyond the intervertebral foramen, [36][37][38] our findings seem to provide a more likely mechanism for such spread.…”

Anatomy and Pathophysiology of Spinal Cord Injury Associated With Regional Anesthesia and Pain Medicine

“…Importantly, wakefulness is not limited as a monitor of nerve injury but may also play a role in recognizing neuraxial-related complications such as high spinal anesthesia or evolving local anesthetic systemic toxicity. 30,162 Neuraxial Anesthesia in the Anesthetized or Deeply Sedated Pediatric Patient Although the absolute risks in either scenario are unknown, as stated in our 2008 practice advisory, "the argument to perform neuraxial anesthesia in anesthetized or deeply sedated children is predicated on the likely higher risk of injuring a moving and/or uncooperative child during placement of a neuraxial-directed needle versus the (presumably) much lower risk of injuring the spinal cord even in the absence of patient feedback." 3 Emerging data from large-scale pediatric registries have strengthened the evidence base for our previous recommendation.…”