Brainstem anaesthesia after retrobulbar block
Regional anaesthesia techniques in ophthalmology are usually utilized for day case surgery. During various procedures, profound akinesia of the eye and anaesthesia of the surgical site are required, both of which are achieved with retrobulbar block. Due to the anatomy of the eye, life-threatening co...
| Main Authors: | , , , |
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| Format: | Article |
| Language: | English |
| Published: |
De Gruyter
2019-03-01
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| Series: | Open Medicine |
| Subjects: | |
| Online Access: | https://doi.org/10.1515/med-2019-0025 |
| _version_ | 1811194317655506944 |
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| author | Kostadinov Ivan Hostnik Andrej Cvenkel Barbara Potočnik Iztok |
| author_facet | Kostadinov Ivan Hostnik Andrej Cvenkel Barbara Potočnik Iztok |
| author_sort | Kostadinov Ivan |
| collection | DOAJ |
| description | Regional anaesthesia techniques in ophthalmology are usually utilized for day case surgery. During various procedures, profound akinesia of the eye and anaesthesia of the surgical site are required, both of which are achieved with retrobulbar block. Due to the anatomy of the eye, life-threatening complications are possible. An 82-year-old female with secondary post-herpetic uveitic glaucoma of the right eye presented at the Department of Ophthalmology for an elective trans-scleral laser cyclophotocoagulation. She was given a retrobulbar block to the right eye with 2 mL of 0.5% levobupivacaine and 2 mL of 2% lidocaine. The procedure was technically performed without any issues. 2-3 minutes after the injection she became lethargic and 5 minutes later she lost consciousness and developed severe hypotension with bradycardia and respiratory arrest. She was successfully intubated and resuscitated, using mechanical ventilation, vasoactive medications, fluid therapy and intravenous lipid emulsion. There are three mechanisms for local anaesthetic (LA) to reach the central nervous system after a retrobulbar block: systemic absorption of LA, direct intra-arterial injection and retrograde flow into the cerebral circulation, and injecting LA into the subdural space via puncturing the dural optic nerve sheath, the latter being most common. The clinical picture of our patient was very consistent with subdural anaesthesia after exposure of the pons, midbrain and cranial nerves to LA, i.e. brainstem anaesthesia. Following appropriate life support measures taken in our case, there was a successful outcome. To minimize the chance for brainstem anaesthesia after retrobulbar block, we recommend low volume with low concentration of LA and block performance by an experienced ophthalmologist or anaesthesiologist with proper technique. Patients receiving retrobulbar anaesthesia should be carefully monitored at least 20 minutes after the block. Life support equipment should be available before performing retrobulbar block. |
| first_indexed | 2024-04-12T00:23:53Z |
| format | Article |
| id | doaj.art-e7028f64f7364e8e9290af3afd1cb81a |
| institution | Directory Open Access Journal |
| issn | 2391-5463 |
| language | English |
| last_indexed | 2024-04-12T00:23:53Z |
| publishDate | 2019-03-01 |
| publisher | De Gruyter |
| record_format | Article |
| series | Open Medicine |
| spelling | doaj.art-e7028f64f7364e8e9290af3afd1cb81a2022-12-22T03:55:36ZengDe GruyterOpen Medicine2391-54632019-03-0114128729110.1515/med-2019-0025med-2019-0025Brainstem anaesthesia after retrobulbar blockKostadinov Ivan0Hostnik Andrej1Cvenkel Barbara2Potočnik Iztok3Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Zaloška 7, 1000Ljubljana, SloveniaClinical Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, SloveniaDepartment of Ophthalmology, University Medical Centre Ljubljana, Ljubljana, SloveniaMedical Faculty, University of Ljubljana, Ljubljana, SloveniaRegional anaesthesia techniques in ophthalmology are usually utilized for day case surgery. During various procedures, profound akinesia of the eye and anaesthesia of the surgical site are required, both of which are achieved with retrobulbar block. Due to the anatomy of the eye, life-threatening complications are possible. An 82-year-old female with secondary post-herpetic uveitic glaucoma of the right eye presented at the Department of Ophthalmology for an elective trans-scleral laser cyclophotocoagulation. She was given a retrobulbar block to the right eye with 2 mL of 0.5% levobupivacaine and 2 mL of 2% lidocaine. The procedure was technically performed without any issues. 2-3 minutes after the injection she became lethargic and 5 minutes later she lost consciousness and developed severe hypotension with bradycardia and respiratory arrest. She was successfully intubated and resuscitated, using mechanical ventilation, vasoactive medications, fluid therapy and intravenous lipid emulsion. There are three mechanisms for local anaesthetic (LA) to reach the central nervous system after a retrobulbar block: systemic absorption of LA, direct intra-arterial injection and retrograde flow into the cerebral circulation, and injecting LA into the subdural space via puncturing the dural optic nerve sheath, the latter being most common. The clinical picture of our patient was very consistent with subdural anaesthesia after exposure of the pons, midbrain and cranial nerves to LA, i.e. brainstem anaesthesia. Following appropriate life support measures taken in our case, there was a successful outcome. To minimize the chance for brainstem anaesthesia after retrobulbar block, we recommend low volume with low concentration of LA and block performance by an experienced ophthalmologist or anaesthesiologist with proper technique. Patients receiving retrobulbar anaesthesia should be carefully monitored at least 20 minutes after the block. Life support equipment should be available before performing retrobulbar block.https://doi.org/10.1515/med-2019-0025retrobulbar block complicationsbrainstem anaesthesialocal anaesthetic toxicity |
| spellingShingle | Kostadinov Ivan Hostnik Andrej Cvenkel Barbara Potočnik Iztok Brainstem anaesthesia after retrobulbar block Open Medicine retrobulbar block complications brainstem anaesthesia local anaesthetic toxicity |
| title | Brainstem anaesthesia after retrobulbar block |
| title_full | Brainstem anaesthesia after retrobulbar block |
| title_fullStr | Brainstem anaesthesia after retrobulbar block |
| title_full_unstemmed | Brainstem anaesthesia after retrobulbar block |
| title_short | Brainstem anaesthesia after retrobulbar block |
| title_sort | brainstem anaesthesia after retrobulbar block |
| topic | retrobulbar block complications brainstem anaesthesia local anaesthetic toxicity |
| url | https://doi.org/10.1515/med-2019-0025 |
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