Total Spinal Blockage after Spinal Anaesthesia for Perianal Fistula-Juniper Publishers
Juniper Publishers-Journal of Anesthesia
Abstract
Total spinal block is one of the rare complications
of regional anaesthesia. It can occur after spinal, epidural or nerve
plexus block. Early detection and treatment is essential to prevent
mortality. We report a case of total spinal block occurring in a man
with perianal fistula after receiving uneventful spinal anaesthesia for
caesarean section treated successfully with prompt cardiovascular
resuscitation and general anaesthesia.
Introduction
Spinal anaesthesia is being increasing used as a mode of anaesthesia for performing treatment for perianal fistula [1].
Although it is a safe and effective means of giving anaesthesia, at
times it can lead to complications like hypotension, shivering,
respiratory distress, unconsciousness, etc [2].
Total spinal block is a rare complication of spinal anaesthesia. It is a
life threatening complication presenting with symptoms of
unconsciousness, hypotension, bradycardia and respiratory failure [3].
We report a case of total spinal block occurring in
young man after receiving uneventful spinal anaesthesia for perianal
treatment. The patient was successfully treated with prompt
cardiovascular resuscitation and general anaesthesia.
Case Description
We report a case of 33 years old man, ASA 1 admitted for treatment of perianal fistula that has evolved since 3 years.
In surgical history, he was operated two times for
perianl abcess, first time in 2012, and second time one year ago, the
two operations were made under general anesthesia without any
intraoperative complications. No history of any medical illness or
allergy.
On pre-anesthetic examination patient was in good
general condition with weight of 88 kg, height 1.80 m, and body mass
index of 27.16 kg/m2. Respiratory and cardio vascular examination were
unremarkable. Patient had thoracolumbar scoliosis since the age of 18
years.
Laboratory tests include: hemoglobin: 10.8 gm%, platelets count: 2.36 x 105/mm3, glucose: 0.81 mumol/, blood group: O negative.
Patient was explained about the procedure of spinal
anaesthesia. During induction, patient was placed in lateral decubitus,
with standard hemodynamic monitoring. At induction his hemodynamic
condition was stable (blood pressure: 120 / 80 mmHg, pulse rate: 75b /
min, SPO2: 100%). Intravenous access was taken in the peripheral vein of
both arms with 18 G vein flow needle and prefilled with 750 ml of 0.9%
normal saline. Classic single shot spinal anesthesia was given with 27G
spinal needle in the first attempt level of block. Slow injection of
08mg of 0.5% isobaric bupivacaine + fentanyl 20gamma was given. His
blood pressure and pulse rate were monitored every 2 minutes. After 4
minutes of spinal anesthesia, and before anal dilatation, patient
started experiencing respiratory discomfort, nausea and vomiting. There
was sudden fall in blood pressure (BP) to 60/30 mmHg and desaturation
(SPO2: 70%) with pulse of 70b / min. Patient became unconscious. There
was bilateral nystagmus, and mydriasis on pupil examination.
Subsequently patient became dyspneic followed by apnea. Hence ephedrine
was administered intravenously 9 mg bolus every 2 minutes along with
mask ventilation with 100% pure oxygen.
The hemodynamics further worsened to unrecordable BP
and SpO2 (oxygen saturation) between 60-70% despite mask ventilation. As
patient failed to respond to any medication, we went ahead with rapid
induction (drugs used: 300mg pentothal + 300mg gamma fentanyl + 50mg
rocuronium) and orotracheal intubation. After intubation, SpO2 improved
to 80-90%. But hemodynamics continued to remain unstable (systolic BP:
50-80mmHg, pulse rate: 120b / min). Repeated adrenaline injections
(0.2mg / every 05min) were given along with intraoperative volume
replacement rate of 2.5 macromolecules litre. Throughout the duration of
resuscitation, pulmonary auscultation was normal without any evidence
of bronchospasm. The diagnosis of complete spinal block was made.
After 120 minutes of continued hemodynamic and
respiratory support, improvement in the hemodynamic state and
respiration was noted (BP: 80-120 / 30-50mmHg, heart rate: 100-120 b /
min, SPO2 90-95%)
As the hemodynamics stabilized with signs of
respiratory efforts, we gradually withdrew vasoactive narcotic drugs.
After 5 hours of spinal anesthesia, there was regain of consciousness
with spontaneous breathing efforts. Patient kept under artificial
assisted controlled intermittent ventilation and pressure support for
two hours and then extubated.
Subsequently, pure oxygen was administered through
the nose for 05 hours and analgesic medications were given for pain
relief. Patient was discharged on postoperative day 3 without any
neurological or clinical sequelae. Patient was advised to avoid spinal
anesthesia in future.
Discussion
Spinal anaesthesia is one of the preferred procedures
for proctology as it is safe, effective and provides good postoperative
analgesia [4].
Cardio-respiratory failure after spinal anaesthesia for perianal
fistula is rare. It can occur due to total spinal block, anaphylactic
reaction to anesthetic drugs, etc. In the present case, since there was
cardio-respiratory failure followed by unconsciousness, total or high
spinal blockage was suspected. But considering the fact that the
procedure of spinal anesthesia was uneventful and the drugs were used in
the routine doses, the cause of total spinal block could not be
ascertained.
Total spinal block has been reported after epidural test dose [5], lumbar plexus block [2],
etc. It occurs because of various technical reasons like use of higher
dose of anesthetics, accidental subdural puncture, rapid change of
posture, etc. Thoracolumbar scoliosis may have acted as an indirect risk
factor for development of total spinal anesthesia.
Conclusion
To conclude, total spinal block is a rare
complication which should be kept in mind while monitoring patient after
spinal anaesthesia. Immediate resuscitation with intravenous fluids,
inotropic and respiratory support can help tide over the acute crisis.
For more articles in Journal of Anesthesia
& Intensive Care Medicine please click on:
https://juniperpublishers.com/jaicm/index.php
https://juniperpublishers.com/jaicm/index.php
Comments
Post a Comment