SummaryA 66-year-old patient scheduled for elective shoulder surgery underwent a brachial plexus block using the posterior approach. Shortly after injection of the local anaesthetic, he rapidly became unresponsive and apnoeic. We identify the possible reasons for this occurrence and discuss the place of the posterior approach in brachial plexus anaesthesia. There are a number of approaches to the upper trunk of the brachial plexus that anaesthetists can use to provide anaesthesia and analgesia for shoulder surgery. The lateral interscalene or Winnie approach is currently the most popular. However, recent articles on the posterior approach have provoked a discussion about the preferred approach and the better technique [1]. Although the approaches are generally safe, significant complications have been described with both. Total spinal anaesthesia is very rare with the posterior approach and may be due to anatomical variations, technical performance or both [1,2]. An understanding of the factors associated with these complications may help to decrease their incidence.
Case reportA 66-year-old man (weight: 93 kg; height: 1.83 m) presented for elective left shoulder hemi-arthroplasty. His medical history included hypertension and an episode of acute coronary syndrome for which he had undergone angioplasty. His routine medication comprised carbasalate calcium, metoprolol, isosorbide-5 mononitrate, diltiazem, captopril, oxazepam, pravastatin and omeprazole. He had not previously undergone surgery or anaesthesia.An 18G intravenous cannula was inserted in the anaesthetic room and an ECG, pulse oximeter and blood pressure cuff were attached. After the subcutaneous injection of lidocaine 1% 2 ml, a brachial plexus block was to be performed by an experienced anaesthetist using the posterior approach with the patient in the sitting position [3]. A Contiplex Tuohy needle (B Braun, Melsungen, Germany) attached to a Stimuplex HNS 11 stimulator (B Braun, Melsungen, Germany) was used with initial stimulator settings of: frequency ¼ 2 Hz; stimulus duration ¼ 0.2 ms; current ¼ 5 mA.Before the needle could be inserted, the patient developed a bradycardia for which intravenous atropine 0.5 mg was given. After the heart rate had returned to normal, he was laid down in the right lateral position. After insertion of the needle, evoked contractions of biceps brachialis and the wrist flexors were produced at a current of 0.3 mA. Levobupivacaine 0.5% 40 ml were injected after negative aspiration before and after every 5 ml of solution injected. The evoked contractions ceased immediately after the start of the local anaesthetic injection. During the injection of the last 5 ml of local anaesthetic, the patient suddenly became unresponsive and apnoeic. The injection was stopped immediately.His blood pressure at this time was 60 ⁄ 30 mmHg with a heart rate of 60 beats.min )1 . His lungs were ventilated with oxygen 100% with a bag, mask and valve. His trachea was then intubated without the need for a neuromuscular blocking drug. He was put in...
