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Hohe sekundäre Ausbreitung einer Spinalanästhesie mit isobarem 0,5%igem Bupivacain nach spätem Lagewechsel

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Zusammenfassung

Im Rahmen von Spinalanästhesien (SPA) kann die Ausbreitung der sensorischen und sympathischen Blockade durch Lagewechsel sowohl nach der Anwendung von isobaren wie auch hyperbaren Lokalanästhetika (LA) unvorhersehbar zunehmen. Wir berichten in diesem Zusammenhang über einen 50-jährigen adipösen Patienten, bei dem zur Versorgung einer Unterschenkelfraktur eine SPA mit 17,5 mg 0,5%igem isobarem Bupivacain durchgeführt wurde. Nach 15 min erreichte die Ausbreitung der sensorischen Blockade ihr Maximum bei Th8. Nach 15° Oberkörperhochlagerung, 35 min nach der intrathekalen Injektion des LA, kam es innerhalb der nächsten 10 min zu einer unbeabsichtigten Zunahme der kranialen Ausbreitung um 10 Segmente bis C6. Der Patient wurde bradykard, hypoton, respiratorisch insuffizient und musste intubiert und beatmet werden. Die Hämodynamik wurde durch die intravenöse Applikation von Akrinor®, Atropin und kolloidalen Volumenersatzmitteln rasch stabilisiert. Die anschließende Operation erfolgte ohne Besonderheiten in Intubationsnarkose. Bei Operationsende wurde der Patient bei stabiler Hämodynamik und suffizienter Spontanatmung problemlos extubiert. Unmittelbar nach Extubation erreichte die kraniale sensorische Ausbreitung L2. Die Kasuistik zeigt, dass es auch nach vermeintlicher Fixierung des LA zu einer unerwarteten Zunahme der Blockade nach Lagewechsel kommen kann, und dass Patienten nach SPA bis zur Remission der Blockade sorgfältig überwacht werden müssen. Die der unbeabsichtigten kranialen Ausbreitung von sensorischer und sympathischer Blockade zugrunde liegenden Pathomechanismen werden diskutiert.

Abstract

Inadvertent cranial extension of sympathetic and sensory block following posture change during spinal anaesthesia has been reported for isobaric as well as for hyperbaric local anaesthetics. We present the case of a patient who underwent surgical repair of a refracture of the tibia under spinal anaesthesia with 17.5 mg of isobaric 0.5% bupivacaine. The maximum level of sensory block (MLSB) reached T8 after 15 min. Following posture change into a 15° anti-Trendelenburg position 35 min after lumbar puncture, the MLSB increased cranially for 10 segments and reached the C6 level after 10 min of anti-Trendelenburg position. The patient suffered from severe bradycardia and arterial hypotension which were treated with 6% hydroxyethyl starch, atropine and Akrinor®. In addition, the patient developed respiratory insufficiency and was therefore intubated and the lungs were mechanically ventilated. The operation was performed uneventfully with the patient under general anaesthesia. At the end of surgery the trachea was extubated, and the patient was awake with stable hemodynamics, sufficient spontaneous ventilation and free of pain. MLSB reached the second lumbar dermatome. This case shows that after assumed fixation of the local anaesthetic an inadvertent extension of the MLSB following posture change is possible. Close surveillance is recommended for patients with central neuraxial blocks until the block is in complete remission. The mechanisms for inadvertent high extension of the MLSB following posture change are discussed.

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Authors and Affiliations

  1. Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Carl-Gustav-Carus, TU Dresden

    O. Vicent, R. J. Litz, M. Hübler & T. Koch

  2. Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Carl-Gustav-Carus, TU Dresden, Fetscherstraße. 74, 01307, Dresden

    O. Vicent

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  1. O. Vicent
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  2. R. J. Litz
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  3. M. Hübler
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  4. T. Koch
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Correspondence to O. Vicent.

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Vicent, O., Litz, R.J., Hübler, M. et al. Hohe sekundäre Ausbreitung einer Spinalanästhesie mit isobarem 0,5%igem Bupivacain nach spätem Lagewechsel. Anaesthesist 52, 1035–1038 (2003). https://doi.org/10.1007/s00101-003-0578-8

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  • DOI: https://doi.org/10.1007/s00101-003-0578-8

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