ANESTHESIA AND ANALGESIA . . . Current Researches VOL. 56, No. 3, MAY-JUNE, 1911
446
caliber make it an excellent site for percutaneous venipuncture. The shorter, more direct route to the right atrium offers another advantage. This introduction set is specifically designed for internal jugular cannulation. The length of the dilator (17 cm) and sheath (9 cm) allow entry under diverse anatomic conditions. Use of the Luer-Lok@has minimized the potential risk of inadvertent passage of a dislodged sheath or dilator into the heart. An added benefit is the fact that the 8-French sheath can be used for rapid administration of large volumes of fluid. To date, we have successfully used this technic in more than 340 insertions.2
REFERENCES 1. Swan HJC: Balloon flotation catheters: their use in hernodynamic monitoring in clinical practice. JAMA 233:865-867, 1975 2. Seldinzer SI: Catheter reolacement of the needle in percutaneous arteriography. Acta Radio1 39:368-376, 1953 3. Defalque RJ: Percutaneous catheterization of the internal jugular vein. Anesth Analg 53:116-121, 1974 4. Webre DR, Arens JF: Use of the cephalic and basilic veins for introduction of central venous catheters. Anesthesiology 38:389-392, 1973 5. Katz J, Cronau L, Mandel S, et al: Pulmonary artery flow guided catheters in the peri-operative period: indications and complications-an analysis of 340 consecutive insertions. Crit Care Med 4:99, 1976
Cardiac Arrest After lnterscalene Brachial-Plexus Block R. RICHARD EDDE, M D * STANLEY DEUTSCH, PhD, M D t
Oklahoma City, Oklahoma$
I
brachial-plexus block has become a popular method of anesthesia for surgical operations on the upper extremities. Reported complications have been few and generally without prolonged effects.l-3 We are describing a case of cardiac arrest following interscalene brachial-plexus block, with a brief review of the possible complications. NTERSCALENE
acid, pyridoxine, iron sulfate, calcium gluconate, quinine tablets, and doxycycline. He was allergic to codeine and oxycodone. Preoperative hemoglobin was 4.2, hematocrit, 12.6; serum K’ was 4.2 mEq/L; and ECG revealed ST-T wave changes in the anterolateral leads; chest x-ray was normal. On the morning of operation he was given InnovaP (1 rnl) and atropine (0.4 mg) I M and taken to the operating room for the induction of a right interscalene brachialplexus block.
REPORT OF A CASE A 31-year-old man was admitted to University Hospital for the excision of a right The usual monitoring devices were apbrachial-artery aneurysm. He had a long history of chronic renal failure following plied, including blood pressure, pulse, and bilateral nephrectomy, requiring weekly di- ECG. The right side of neck was prepared alysis. Significant past medical history in- and draped in a sterile manner. An intercluded congestive heart failure, hyperten- scalene brachial-plexus block was performed, sion, and hypocalcemia, which were under using landmarks as described by Winnie,4 good control at the time of operation. He although a 6-cm needle was employed inhad undergone numerous local-anesthetic stead of the 3.8 cm needle described by procedures for the creation of A-V fistulas. Winnie. Paresthesias were obtained and 20 Medications included folic acid, ascorbic ml of bupivacaine 0.5 percent was injected. *Assistant Professor, Department of Anesthesiology. ?Professor and Head, Department of Anesthesiology. $Health Sciences Center, The University of Oklahoma, Oklahoma City, Oklahoma 73190. Paper received: 4/30/76 Accepted for publication: 9/10/76
447
Brief Reports
The patient noted numbness of his right arm. Aspiration before, during, and after injection revealed no blood or cerebrospinal fluid. Immediately after removal of the needle, the patient experienced cardiopulmonary arrest, with an ECG that revealed ventricular fibrillation. His trachea was intubated and he was given 100 percent 0 2 ,NaHC03, epinephrine, and calcium chloride. Defibrillation with 400 watt-seconds restored cardiac rhythm to a sinus tachycardia. Arterial blood gases immediately after resuscitation revealed a mixed respiratory and metabolic alkalosis. In the recovery room, the patient remained in a comatose state, requiring a volume-cycled ventilator. His pupils were dilated and fixed and he did not respond to painful or caloric stimuli. However, during the next hour in the recovery room he awoke, was extubated, and was normal to neurologic examination. Two days later, his aneurysm was excised without problems under axillary block.
DISCUSSION Complications following interscalene brachial-plexus block have included hematoma formation, subarachnoid injection, phrenicnerve paralysis, Horner’s syndrome, recurrent laryngeal-nerve paralysis, pneumothoTax, and development of transient carotid br~its.~-~ Pharmacologically, bupivacaine has been reported to produce cardiac arrhythmias, anaphylaxis, and cardiac arrest. Among the arrhythmias, bradycardia was the most common.7 Intravenous injection was probably not a factor in our patient, as frequent
needle aspiration was carried out during the procedure. Although hyperkalemia can precipitate ventricular tachycardia and fibrillation, our patient had been adequately dialyzed prior to operation and his serum K’ was normal. We feel that the most likely cause of his cardiac arrest was an inadvertent subarachnoid injection resulting in a “total spinal,” with medullary ischemia8 characterized by persistent apnea and failure to regain consciousness. The chance of this occurring was increased by the use of a long ( 6 cm) needle. To minimize the probability of this hazard, a short, 3-cm needle should be employed in interscalene brachial-pleux block.
REFERENCES 1. Lund PC, Cwik JC, Vallesteros F: Bupivacaine-a new long-acting local anesthetic agent. A preliminary clinical and laboratoy report. Anesth Analg 49: 103-114, 1970 2. Beck L, Martin K: Hazards associated with paracervical block. Ger Med Mon 15:80-83, 1970
3. Moore DC, Bridenbaugh LD, Bridenbaugh PO, et al: Bupivacaine. A review of 2077 cases. JAMA 214: 713-718, 1970 4. Winnie AP: Interscalene brachial plexus block. Anesth Analg 49:455-466, 1970 5. Moore DC: Complications of regional anesthesia. Clin Anesth 2:218-251, 1969 6. Siler J N , Lief PF, Davis FJ: A new complication of interscalene brachial-plexus block. Anesthesiology 38:590-591, 1973 7. Widman B: Some circulatory and respiratory effects of intravenous local anaesthetics. Acta Anaesthesiol Scand Suppl 25:34-36, 1966 8. Benumof JL, Semenza 5: Total spinal anesthesia following intrathoracic intercostal nerve blocks. Anesthesiology 43: 124-125, 1975 9. Robinson WM, Jenkins LC: Central nervous system effects of bupivacaine. Can Anaesth SOCJ 22: 358-369, 1975
446
caliber make it an excellent site for percutaneous venipuncture. The shorter, more direct route to the right atrium offers another advantage. This introduction set is specifically designed for internal jugular cannulation. The length of the dilator (17 cm) and sheath (9 cm) allow entry under diverse anatomic conditions. Use of the Luer-Lok@has minimized the potential risk of inadvertent passage of a dislodged sheath or dilator into the heart. An added benefit is the fact that the 8-French sheath can be used for rapid administration of large volumes of fluid. To date, we have successfully used this technic in more than 340 insertions.2
REFERENCES 1. Swan HJC: Balloon flotation catheters: their use in hernodynamic monitoring in clinical practice. JAMA 233:865-867, 1975 2. Seldinzer SI: Catheter reolacement of the needle in percutaneous arteriography. Acta Radio1 39:368-376, 1953 3. Defalque RJ: Percutaneous catheterization of the internal jugular vein. Anesth Analg 53:116-121, 1974 4. Webre DR, Arens JF: Use of the cephalic and basilic veins for introduction of central venous catheters. Anesthesiology 38:389-392, 1973 5. Katz J, Cronau L, Mandel S, et al: Pulmonary artery flow guided catheters in the peri-operative period: indications and complications-an analysis of 340 consecutive insertions. Crit Care Med 4:99, 1976
Cardiac Arrest After lnterscalene Brachial-Plexus Block R. RICHARD EDDE, M D * STANLEY DEUTSCH, PhD, M D t
Oklahoma City, Oklahoma$
I
brachial-plexus block has become a popular method of anesthesia for surgical operations on the upper extremities. Reported complications have been few and generally without prolonged effects.l-3 We are describing a case of cardiac arrest following interscalene brachial-plexus block, with a brief review of the possible complications. NTERSCALENE
acid, pyridoxine, iron sulfate, calcium gluconate, quinine tablets, and doxycycline. He was allergic to codeine and oxycodone. Preoperative hemoglobin was 4.2, hematocrit, 12.6; serum K’ was 4.2 mEq/L; and ECG revealed ST-T wave changes in the anterolateral leads; chest x-ray was normal. On the morning of operation he was given InnovaP (1 rnl) and atropine (0.4 mg) I M and taken to the operating room for the induction of a right interscalene brachialplexus block.
REPORT OF A CASE A 31-year-old man was admitted to University Hospital for the excision of a right The usual monitoring devices were apbrachial-artery aneurysm. He had a long history of chronic renal failure following plied, including blood pressure, pulse, and bilateral nephrectomy, requiring weekly di- ECG. The right side of neck was prepared alysis. Significant past medical history in- and draped in a sterile manner. An intercluded congestive heart failure, hyperten- scalene brachial-plexus block was performed, sion, and hypocalcemia, which were under using landmarks as described by Winnie,4 good control at the time of operation. He although a 6-cm needle was employed inhad undergone numerous local-anesthetic stead of the 3.8 cm needle described by procedures for the creation of A-V fistulas. Winnie. Paresthesias were obtained and 20 Medications included folic acid, ascorbic ml of bupivacaine 0.5 percent was injected. *Assistant Professor, Department of Anesthesiology. ?Professor and Head, Department of Anesthesiology. $Health Sciences Center, The University of Oklahoma, Oklahoma City, Oklahoma 73190. Paper received: 4/30/76 Accepted for publication: 9/10/76
447
Brief Reports
The patient noted numbness of his right arm. Aspiration before, during, and after injection revealed no blood or cerebrospinal fluid. Immediately after removal of the needle, the patient experienced cardiopulmonary arrest, with an ECG that revealed ventricular fibrillation. His trachea was intubated and he was given 100 percent 0 2 ,NaHC03, epinephrine, and calcium chloride. Defibrillation with 400 watt-seconds restored cardiac rhythm to a sinus tachycardia. Arterial blood gases immediately after resuscitation revealed a mixed respiratory and metabolic alkalosis. In the recovery room, the patient remained in a comatose state, requiring a volume-cycled ventilator. His pupils were dilated and fixed and he did not respond to painful or caloric stimuli. However, during the next hour in the recovery room he awoke, was extubated, and was normal to neurologic examination. Two days later, his aneurysm was excised without problems under axillary block.
DISCUSSION Complications following interscalene brachial-plexus block have included hematoma formation, subarachnoid injection, phrenicnerve paralysis, Horner’s syndrome, recurrent laryngeal-nerve paralysis, pneumothoTax, and development of transient carotid br~its.~-~ Pharmacologically, bupivacaine has been reported to produce cardiac arrhythmias, anaphylaxis, and cardiac arrest. Among the arrhythmias, bradycardia was the most common.7 Intravenous injection was probably not a factor in our patient, as frequent
needle aspiration was carried out during the procedure. Although hyperkalemia can precipitate ventricular tachycardia and fibrillation, our patient had been adequately dialyzed prior to operation and his serum K’ was normal. We feel that the most likely cause of his cardiac arrest was an inadvertent subarachnoid injection resulting in a “total spinal,” with medullary ischemia8 characterized by persistent apnea and failure to regain consciousness. The chance of this occurring was increased by the use of a long ( 6 cm) needle. To minimize the probability of this hazard, a short, 3-cm needle should be employed in interscalene brachial-pleux block.
REFERENCES 1. Lund PC, Cwik JC, Vallesteros F: Bupivacaine-a new long-acting local anesthetic agent. A preliminary clinical and laboratoy report. Anesth Analg 49: 103-114, 1970 2. Beck L, Martin K: Hazards associated with paracervical block. Ger Med Mon 15:80-83, 1970
3. Moore DC, Bridenbaugh LD, Bridenbaugh PO, et al: Bupivacaine. A review of 2077 cases. JAMA 214: 713-718, 1970 4. Winnie AP: Interscalene brachial plexus block. Anesth Analg 49:455-466, 1970 5. Moore DC: Complications of regional anesthesia. Clin Anesth 2:218-251, 1969 6. Siler J N , Lief PF, Davis FJ: A new complication of interscalene brachial-plexus block. Anesthesiology 38:590-591, 1973 7. Widman B: Some circulatory and respiratory effects of intravenous local anaesthetics. Acta Anaesthesiol Scand Suppl 25:34-36, 1966 8. Benumof JL, Semenza 5: Total spinal anesthesia following intrathoracic intercostal nerve blocks. Anesthesiology 43: 124-125, 1975 9. Robinson WM, Jenkins LC: Central nervous system effects of bupivacaine. Can Anaesth SOCJ 22: 358-369, 1975
