Brief Communications be evaluated before choosing to anesthetize a patient Total spinal anaesthesia with with ALS. A non‑paralytic general anaesthesia with regional nerve block ensured anesthesia, immobility “Interscalene brachial plexus and analgesia in our patient. block by Winnie approach” Suma M Thampi, Deepu David1, Tony Thomson Chandy, Amar Nandhakumar Introduction Departments of Anesthesia, 1Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India Several reports have described spinal or epidural Address for correspondence: anaesthesia resulting from attempted blockade of Dr. Tony Thomson Chandy, brachial plexus by interscalene route. Total spinal Department of Anesthesia, Christian Medical College and Hospital, anaesthesia is very rare and may be due to anatomical Vellore, Tamil Nadu, India. E‑mail: [email protected] variations, technical performance or both. An understanding of the factors associated with these REFERENCES complications may help to decrease their incidence.

1. Soriani MH, Desnuelle C. [Epidemiology of amyotrophic lateral sclerosis]. Rev Neurol (Paris) 2009;165:627‑40. Case REPORT 2. Campbell WW, DeJong RN. DeJong’s the neurologic th examination. 7 ed. Philadelphia, PA: Lippincott Williams and A 35‑year‑old patient of American society of Wilkins;2012. 3. Shoesmith CL, Findlater K, Rowe A, Strong MJ. Prognosis of anaesthesiologists ASA grade 1 with fracture amyotrophic lateral sclerosis with respiratory onset. J Neurol dislocation of the right head of radius and fracture Neurosurg Psychiatry 2007;78:629‑31. rd 4. Just N, Bautin N, Danel‑Brunaud V, Debroucker V, Matran R, lateral 3 of the clavicle scheduled for surgery under Perez T. The Borg dyspnoea score: A relevant clinical marker of brachial plexus block with sedation. inspiratory muscle weakness in amyotrophic lateral sclerosis. Eur Respir J 2010;35:353‑60. 5. Hara K, Sakura S, Saito Y, Maeda M, Kosaka Y. Epidural After local anaesthesia with 2% lignocaine, a anesthesia and pulmonary function in a patient with needle was advanced between belly of anterior amyotrophic lateral sclerosis. Anesth Analg 1996;83:878‑9. and middle scalene at the level of cricoid cartilage 6. Gattenlohner S, Schneider C, Thamer C, Klein R, Roggendorf W, Gohlke F, et al. Expression of foetal type or C6 as described by Winnie. After eliciting acetylcholine receptor is restricted to type 1 muscle fibres in nerve paraesthesia, a mixture of 30 ml (0.5% human neuromuscular disorders. Brain 2002;125:1309‑19. bupivacaine ‑ 20 ml tramadol ‑ 1 ml 9 ml normal 7. Dripps RD, Vandam LD. Exacerbation of pre‑existing + + neurologic disease after spinal anesthesia. N Engl J Med saline (NS) was injected slowly with negative 1956;255:843‑9. aspiration after each 3‑5 ml. Even after a proper caution 8. Vercauteren M, Heytens L. Anaesthetic considerations for patients with a pre‑existing neurological deficit: Are patient moved his neck during the last 5 ml injection. neuraxial techniques safe? Acta Anaesthesiol Scand 2007; Immediately after injection, the patient became 51:831‑8. unconscious and apnoeic, with loss of muscle tone in 9. Guay J. First, do no harm: Balancing the risks and benefits of regional anesthesia in patients with underlying neurological all extremities. Blood pressure decreased from 120/80 disease. Can J Anaesth 2008;55:489‑94. to 90/60 mmHg and pulse rate from 100 to 80 beats/min. 10. Hebl JR, Horlocker TT, Schroeder DR. Neuraxial anesthesia and analgesia in patients with preexisting central nervous No seizure activity was noted. He had a Glasgow Coma system disorders. Anesth Analg 2006;103:223‑8. Score of 3 and had fixed dilated and unresponsive 11. Fanelli G, Casati A, Garancini P, Torri G. Nerve stimulator pupils. Intravenous fluid was administered, the and multiple injection technique for upper and lower limb blockade: Failure rate, patient acceptance, and neurologic patient was ventilated with oxygen 100% with a bag complications. Study Group on Regional Anesthesia. Anesth mask and his trachea was then intubated without the Analg 1999;88:847‑52. need for a neuromuscular blocking drug. Mechanical ventilation was instituted immediately with 100% Access this article online oxygen. As the patient’s vital parameters noninvasive Quick response code Website: blood pressure (NIBP ‑ 106/70, heart rate (HR) ‑ www.ijaweb.org 78 beats/min) were stable, surgery was begun. It was suspected that total spinal anaesthesia had occurred. Pupils were initially noted to be widely dilated but DOI: 10.4103/0019-5049.111863 gradually returned to normal size over the course of 1 1 /2 h. Patient’s HR and blood pressure remained stable

Indian Journal of Anaesthesia | Vol. 57| Issue 2 | Mar-Apr 2013 199 Brief Communications during 1st h post‑injection, then the HR gradually This early sign persisted for 45 min, at which time HR decreased to 50 beats/min. 0.5 mg of atropine was decreased to 50 beats/min. This evidence of the high, but given for bradycardia, HR gradually increased to not intracranial blockade persisted for approximately 1 80 beats/min. 1 /2 h. At the conclusion of the case, patient appeared to have recovered completely. After 1 h 15 min, spontaneous effort was seen gradually and patient was able to follow command In our case, there is no recall of events which was and adequate tidal volume by 1 h 48 min. Patient was consistent with previously published reports by Ross extubated with an adequate gag reflex. Patient was able and Scarborough.[4] There was no seizure activity or to move all the extremities on the command except myocardial depression that might have resulted from the operated right arm. There was no response by the intravenous injection of lidocaine or bupivacaine.[5] patient to the surgical manipulation of the right arm. Durrani and Winnie[6] have described a lock in syndrome The right (operating) arm had proximal motor strength resulting from probable intra‑arterial injection of 0/5. At 3 h post‑injection, right arm strength and accompanying a successful brachial plexus block sensation had returned to normal. After completion but there was no seizure activity and this rules out of surgery, patient was shifted to an intensive care intravascular injection of local anaesthetics. Unlike unit with oxygen via face mask. Close questioning on intravenous or intra‑arterial injection, cerebrospinal fluid day one of the post‑operative, revealed no recall of administration of local anaesthetics such as procaine intra‑operative events. caused nystagmus, defecation, vomiting, respiratory depression, loss of consciousness after 15‑30 min but Discussion was not associated with seizure activity in a dog.[7]

After interscalene blocks, various complications have Despite high sympathectomy and some degree of the been reported, including total spinal anaesthesia and parasympathetic blockade at the brain stem level Horner’s syndrome.[1,2] patient’s HR and blood pressure remained at an acceptable level throughout and the patient did not In our case, the possibility of intrathecal injection require vasopressors or chronotropic drugs.[8,9] Direct of anaesthetic agent should be considered. Local application of local anaesthetics at the medullary anaesthetics can enter the spinal space through at region of the central nervous system results in least three different routes. First, the drug may be hypotension, bradycardia, ventricular arrhythmias.[10] injected directly intrathecally. Second, a dural cuff sometimes may accompany a nerve root distal to the CONCLUSION intervertebral foramen, which may be accidentally punctured, making direct intrathecal injection possible. In summary, we once again emphasise the importance All authors who reported total spinal anaesthesia of careful technique, monitoring, immediate access to claimed to have had negative aspiration tests, which resuscitation equipment while performing block. therefore, did not guarantee absolute safety. Finally, local anaesthetics injected intraneurally could spread Anil Kumar Verma, Mukesh Kumar Sah, in a central direction to the spinal space. After near Apurva Agarwal, Chandshekhar Singh completion of block last few millilitre of anaesthetic Department of Anaesthesiology and Critical Care, GSVM Medical College, Kanpur, Uttar Pradesh, India was injected either to epidural or subarachnoid space at C6 probably by advancement of needle into the Address for correspondence: intervertebral foramina. Rapidity with which symptoms Dr. Mukesh Kumar Sah, developed (unconsciousness, apnoea) argues for some Senior Resident, Department of Anaesthesiology and Critical Care Dr. R. M. L. Hospital, P.G.I.M.E.R, New Delhi ‑1, India degree of subarachnoid injection, although short E‑mail: [email protected] needle used was intended to minimize the risk of this complication. The observation of initially dilated References non‑reactive pupil consistent with the loss of efferent 1. Fernández‑Meré LA, Sopena‑Zubiria LA, Gil‑Soria L, parasympathetic activity from Edinger westphal Alvarez‑Blanco M. Spinal anesthesia after brachial plexus nucleus and the observed bradycardia can be most block with the posterior approach. Rev Esp Anestesiol Reanim 2008;55:63‑4. easily explained by cervicothoracic spinal anaesthesia 2. Frasca D, Clevenot D, Jeanny A, Laksiri L, Petitpas F, Debaene B. with the blockade of cardiac accelerator fibres (T1‑T4).[3] Total spinal anesthesia after interscalenic plexus block. Ann Fr

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Anesth Reanim 2007;26:994‑8. 9. Dutton RP, Eckhardt WF 3rd, Sunder N. Total spinal 3. Winnie AP. Interscalene brachial plexus block. Anesth Analg anesthesia after interscalene blockade of the brachial plexus. 1970;49:455‑66. Anesthesiology 1994;80:939‑41. 4. Ross S, Scarborough CD. Total spinal anesthesia following 10. Thomas RD, Behbehani MM, Coyle DE, Denson DD. brachial‑plexus block. Anesthesiology 1973;39:458. Cardiovascular toxicity of local anesthetics: An alternative 5. Tuominen MK, Pere P, Rosenberg PH. Unintentional arterial hypothesis. Anesth Analg 1986;65:444‑50. catheterization and bupivacaine toxicity associated with continuous interscalene brachial plexus block. Anesthesiology 1991;75:356‑8. Access this article online 6. Durrani Z, Winnie AP. Brainstem toxicity with reversible locked‑in syndrome after intrascalene brachial plexus block. Quick response code Website: Anesth Analg 1991;72:249‑52. www.ijaweb.org 7. Haranath PS, Venkatakrishna‑Bhatt H. Procaine perfused into cerebral ventricles and subarachnoid space in conscious and anaesthetized dogs. Br J Pharmacol 1968;34:408‑16. 8. McGlade DP. Extensive central neural blockade following DOI: interscalene brachial plexus blockade. Anaesth Intensive Care 10.4103/0019-5049.111865 1992;20:514‑6.

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