Accidental brain stem anesthesia leading to hypoxic respiratory failure as a rare complication of local anesthesia infiltration.
CCCF ePoster library. Waters B. Oct 28, 2015; 117341; P122
Dr. Braden Waters
Dr. Braden Waters
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Abstract
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P122


Topic: Case Report


Accidental brain stem anesthesia leading to hypoxic respiratory failure as a rare complication of local anesthesia infiltration.



Braden Waters, B. Waters, J. Muscedere, L. Boissé Lomax, J. Burjorjee

Internal Medicine, Queen's University, Kingston General Hospital, Kingston, Canada | Internal Medicine, Queen`s University, Kingston General Hosptial, Kingston, Canada | Critical Care Medicine, Queen's University, Kingston General Hospital, Kingston, Canada | Neurology, Queen`s University, Kingston General Hospital, Kingston, Canada | Anesthesiology and Perioperative Medicine, Queen’s University, Kingston General Hospital, Kingston, Canada

Introduction:

Iatrogenic cranial nerve palsies can involve multiple cranial nerves and can cause significant patient morbidity, such as such as dysphagia, dysarthria, vision disturbances, and airway obstruction that might require supportive mechanical ventilation and transfer to a critical care unit [1-4]. There are many causes of iatrogenic cranial nerve palsies, such as retrobular blocks for ophthalmologic, post-neurosurgical, otolaryngological and maxillofacial procedures [1-3, 5, 6]. In this report, we present a rare case of evolving multiple cranial nerve palsies leading to brain stem anesthesia with hypoxic respiratory failure during suture revision of a CSF leak in a craniectomy patient.



Objectives:

The objective in presenting this case is to describe, and caution against, a previously unreported phenomenon.



Methods:

N/A



Results:

A 36 year old previously well woman was admitted to our teaching hospital following a traumatic right vertebral artery dissection leading to a right cerebellar infarction. She underwent decompressive occipital craniectomy and recovered rapidly under the neurology service with minimal residual neurological deficits. On the day of her planned discharge, her longitudinal occipital cranial scalp incision was infiltrated with 20cc of 2% lidocaine containing epinephrine in order to re-suture and occlude a suspected CSF leak.

Immediately after infiltration of lidocaine she reported sudden malaise and difficulty breathing. Initial vital signs included: SpO2 of 60% on a 100% non-rebreather mask, BP 124/63 and HR 140. Auscultation of her precordium revealed a silent chest consistent with complete upper airway obstruction. A medical emergency code was called. Her symptoms progressed as she developed slurred speech, and then could not speak. Her pupils became markedly dilated, and she developed a disconjugate gaze, followed by complete ophthalmoplegia that did not respond to the doll’s eye maneuver. Based on this, accidental brainstem anesthesia was urgently diagnosed and she was sedated and intubated for airway protection and ventilation and was transferred to the ICU. The patient remained hemodynamically stable and was extubated 3 hours later. She recalled the onset of the event clearly with sudden tongue numbness and the sensation of having a large immobile tongue which impaired her speech. She was discharged home the following day with no significant neurological deficits.



Conclusion:

In this case, we believe our patient had accidental brain stem anesthesia due to lidocaine infiltration in and around a wound created at the site of occipital craniectomy. We speculate that the mechanism involved was spread of the local anesthetic from the subcutaneous injection site through the tract of the CSF leak and into the cerebral spinal fluid. Systemic lidocaine toxicity was unlikely as plasma lidocaine level was negative. Furthermore, an urgent CT head was unchanged from previous, ruling out an acute infarction or herniation. This is the first reported case of accidental brainstem anaesthesia following local instillation of lidocaine at a craniectomy site. Therefore we believe this demonstrates a novel cause of iatrogenic respiratory failure, and hope this case can be used as a cautionary note for clinicians when infiltrating scalp wounds in craniectomy patients.



References:

1. Mark A. Fritz BJK, Timothy P. Fox, Nicky Bhatia, and Steven M. Mandel.: Iatrogenic hypoglossal nerve palsy. Practical Neurology 2014(January/February):13-16.
2. Cardan E, Azzam A, Simu M: [Extra-arachnoid subdural injection, an accident of peridural anesthesia]. Rev Chir Oncol Radiol O R L Oftalmol Stomatol Chir 1989, 38(2):151-154.
3. Kahn SA, Brandt LJ: Iatrogenic Horner's syndrome: a complication of thoracostomy-tube replacement. N Engl J Med 1985, 312(4):245.
4. Schonfeld CL, Brinkschmidt T: [Brainstem anesthesia with respiratory arrest after retrobulbar block--a case report with a review of literature]. Klin Monbl Augenheilkd 2000, 217(2):130-132.
5. Cavazza S, Bocciolini C, Gasparrini E, Tassinari G: Iatrogenic Horner's syndrome. Eur J Ophthalmol 2005, 15(4):504-506.
6. King RJ, Motta G: Iatrogenic spinal accessory nerve palsy. Ann R Coll Surg Engl 1983, 65(1):35-37.

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