Całkowite znieczulenie rdzeniowe jako powikłanie blokady przykręgowej w odcinku piersiowym – opis przypadku

Hanna Misiołek¹, Hanna Kucia¹, Magdalena Werszner¹, Grzegorz Hura², Piotr Stoksik¹, Piotr Knapik¹

Summary
Background. Thoracic paravertebral nerve blockade has been advocated for minimally-invasive, unilateral surgical procedures of the thorax. It is also of benefit in the prevention and management of postoperative pain. It is a simple procedure and complication rates are low. Among the most common complications are pneumothorax, haemorrhage and Horner´s syndrome. Total spinal block, which occurred in this case, is a very serious but extremely rare complication of this popular technique. Case report. A 67-yr-old male patient with COPD (pneumoconiosis) developed a residual pneumothorax after partial lobectomy. Secondary pleural drainage with pleurodesis was attempted under a paravertebral blockade. The left paravertebral thoracic space was identified using the Eason-Wyatt technique and a 22G pencil point needle. After loss of resistance was felt, and in the presence of a negative aspiration test, a test dose of 2 ml of 1.5% lidocaine was injected without any reaction and it was followed later by a full dose of 0.3 ml kg^-1 of 1,5% lidocaine. Immediately after injection of the full dose, the patient became unconscious and stopped breathing. Systolic blood pressure decreased to 50 mm Hg (6.7 kPa) and heart rate to 50 bpm. The pupils were maximally dilated and non-reactive. The patient was turned supine, intubated without any reaction, and was given 25 mg ephedrine and 10% HES by rapid infusion. Pleural drains were inserted and the patient was transferred to the ICU, where he was connected to a respirator, received inotropic support (dopamine 8 mcg kg^-1 min^-1) and atropine. Two hours after injection, the block resolved and the patient regained consciousness and was extubated. The further clinical course was uneventful. Discussion and conclusion. The frequency of complications following a paravertebral block has been estimated to be between 2.6% to 12.1%. Total spinal blocks are very rare (few cases have been described so far). The possible reasons for this complication include atypical anatomy, wrong technique, or the use of a pencil point needle which partially penetrates the subarachnoidal space making aspiration of the spinal fluid impossible. We conclude that despite the relative safety of a paravertebral block, serious complications may occur and therefore appropriate training and caution are necessary.

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