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Peribulbar block is
given by injecting local anesthetic injection in orbicularis oculi muscle
during ophthalmic surgeries for providing anesthesia, akinesia and analgesia of
the eyeball. Peribulbar block (PBB) is considered a safe block when compared to
retrobulbar block (RBB) because of less chance (0.006%) of complications which
include retrobulbar hemorrhage, eye perforation and optic nerve injury [1].
However, sometimes-dreadful complications like brain stem anesthesia with this
block have been reported [2,3].
A 65 year old male
patient, ASA grade II, controlled chronic obstructive pulmonary disorder,
posted for cataract surgery, was given peribulbar block using 6 ml of 2%
lidocaine and 4 ml of 0.5% bupivacaine with hyaluronidase. The block was
achieved without any resistance and negative aspiration was done for fluid or
blood. Following the block, patient suddenly became restless, agitated, with
feeble pulses, with sudden bradycardia (35-42 bpm) and hypotension (MAP<50
mm Hg), with fall in peripheral oxygen saturation which progressed to loss of
consciousness. The patient was given a bolus of atropine 0.6 mg along with I/V
fluids. Patient was immediately bag mask ventilated with oxygen @ 10 L/min
followed by intubation and mechanical ventilation for 45 min with 100% oxygen.
During this period, his saturation was maintained and vitals remained stable.
As soon he regained consciousness and followed commands, he was extubated and
transferred to the intensive care unit for further follow-up and monitoring. He
was further investigated for possible causes and all investigations were found
to be normal. He was discharged after 24 h of close observation.
On reviewing the
literature, the cause could have been attributed due to an inadvertent
injection of local anesthetic agent into brainstem. As the ophthalmic vessels are
quite close to the brain, if the optic nerve sheath is perforated with the
needle tip, central spread can occur [3]. This is sometimes followed by
respiratory depression and brainstem anesthesia, although the risk for the
development of serious complications is generally low [4]. Even a negative
aspiration, in these vessels does not guarantee that the tip of needle is not
in a vessel as they are very small and thin and negative aspiration can
collapse them giving a false belief of normal periocular injection. The
neurological effects of confusion, agitation, mild convulsion, aphasia,
apparent shivering and unconsciousness may also result from the passage of anesthetic
through blood brain barrier, leading to blockage of inhibitory pathways and secondary
central nervous system excitation. Depending on the volume of anesthetic agent
used, sympathetic hyperactivity can also develop due to involvement of medulla
oblongata leading to excitatory stimulation in vasomotor, respiratory and
vomiting centres resulting in arrhythmias, hypotension and vomiting [4].
Duration of
symptoms may vary from 5-8 min after the administration of peribulbar block
upto 60-90 min after which recovery starts. Residual effect may last for as
long as 2-4 h, therefore postop monitoring in intensive care is required.
Specific Management apart from intubation and mechanical ventilation for
respiratory arrest includes intravenous fluid resuscitation and benzodiazepine
or barbiturates for seizures management. Use of hypodermic needle may also contribute
to CNS complications during peribulbar block. Risk can be decreased by using
shorter needles less than 3 cm, rate of complications using larger needle is
between 0.2-0.3% [4]. In our case, length of needle was short (25 mm), but
complication might have resulted from advancing the needle too far despite
negative aspiration and block provided by a junior resident with less
experience. Use of ultrasound guided peribulbar block can prevent such
complications, but it has few limitations like learning curve,
1.
Kumar CM (2006) Orbital
regional anesthesia: Complications and their prevention. Indian J Ophthalmol
54: 77-84.
2.
Rozentsveig V, Yagev R,
Wecksler N, Gurman G, Lifshitz T, et al. (2001) Respiratory arrest and
convulsions after peribulbar anesthesia. J Cataract Refract Surg 27: 960-962.
3.
Kazancıoğlu L, Batçık Ş, Kazdal
H, Şen A, Gediz BŞ, et al. (2017) Complication of peribulbar block: Brainstem
anesthesia. Turk J Anesthesiol Reanim 45: 231-233.
4.
Palte HD (2015) Ophtalmic
regional blocks: management, challenges and solutions. Local Reg Anesth 8:
57-70.
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