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Anesth Analg 2004;98:1284-1285 © 2004 International Anesthesia Research Society doi: 10.1213/01.ANE.0000108961.49473.11
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Abstract |
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 Top Abstract Case ReportDiscussionReferences |
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Axillary block is used in children for procedures on the hand and forearm. We report on a child with an amputation of the thumb in whom an axillary block was given, after which the limb became pale and pulseless. The pulses returned spontaneously in 15 min. The awareness of this possibility and chances of spontaneous recovery should be considered.
IMPLICATIONS: Transient vascular insufficiency of the upper limb may happen as a rare complication after axillary block. Knowledge of this complication can help the anesthesiologist in the management of this problem.
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Case Report |
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TopAbstractCase ReportDiscussionReferences |
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A 3-yr-old girl with an amputation of the right thumb was brought to the operating room to reimplant the amputated digit. She weighed 15 kg and her hemoglobin concentration was 10 gms%. Physical examination was significant for an upper respiratory tract infection.
The anesthetic plan was to sedate the child and administer an axillary block. She was sedated with 1.5 mg of midazolam and 25 µg of fentanyl. An axillary block was performed with a single needle technique using a 25-gauge needle. Needle placement inside the axillary sheath was confirmed by observing the pulsations of the axillary artery. Ten mL of local anesthetic solution containing 7 mL of 0.5% bupivacaine and 3 mL of 2% lidocaine with adrenaline (1:200,000) was injected. The injection was performed with intermittent aspiration after every 2 mL. After injecting 6 mL there was backflow of blood and hence the needle was repositioned, and after confirming that it was not in the vessel, the rest of the local anesthetic was injected. Pressure was maintained over the injection site to prevent hematoma formation. Two to 3 min later the right upper limb looked paler than the left. On examination the radial, ulnar, and brachial pulsations were not palpable. Pulses were felt only proximal to the site of injection. Neither pulse oximeter nor a Doppler picked up any signals. The injection site was re-examined and there was no evidence of any hematoma. The site was gently massaged. Surgery could not be started without pulsatile flow in the extremity. After 15 min, the color returned slowly with appearance of the brachial and radial pulses. The amputated thumb was then successfully reimplanted. The brachial plexus block lasted for the entire 4-h procedure. The patient was given a supplemental dose of 1 mg of midazolam IV after 2 h. She was administered 50% nitrous oxide with 50% oxygen through a pediatric breathing circuit to keep her still. The child had an uneventful recovery in the postoperative period.
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Discussion |
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TopAbstractCase ReportDiscussionReferences |
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Vascular compromise after an axillary block is a rare. Review of the literature showed one case report by Merrill et al. in 1981 (1). A 49-yr-old patient experienced a decrease in sensation and a feeling of warmth in the arm immediately after the injection of 20 mL of a mixture of lidocaine 1%, tetracaine 0.05%, and epinephrine 1:200,000, 10 mL deep to the artery and 10 mL superficial to it. Approximately 2–3 min later the entire hand and arm blanched. Radial, ulnar, brachial, and axillary pulses were not palpable. No hematoma or mass was palpable in the axilla. Palpable pulses reappeared spontaneously approximately 15 min later. The patient developed a good sensory and motor block and when the block wore off, there were no adverse sequelae.
Possible mechanisms proposed in this case were as follows:
- The effect of intraarterial epinephrine or local anesthetic.
- Mechanical obstruction resulting from subintimal injection into the arterial wall.
- Severe vasospasm attributable to mechanical stimulation by the needle.
- Rapid injection of local anesthetics increasing the pressure in the axillary sheath (3).
Inadvertent injection of even a small amount of local anesthetic solution and adrenaline into a vein causes a rapid increase in the blood level of the drugs and almost invariably results in an immediate systemic reaction. However, injection of a small amount of adrenaline containing local anesthetic solution into the axillary artery is apparently without sequelae, probably because of dilution and clearance of the drug in its circulation through the arm and then the lung. This small amount of adrenaline is enough to cause intense vasoconstriction leading to the absence of the peripheral pulses. Later, when the sympathetic, sensory, and motor block is complete, the resultant increase in blood flow will effectively dilute and wash out the adrenaline sequestrated in the microcirculation of the skin (2). This probably was the cause of the problem in our patient.
The sequence of events in our patient and in the case report of Merrill et al. (1) are the same except that the subjective sensations felt by the patient in Merrill et al.’s case report were absent in our patient, probably because the child was sedated.
Stan et al. (4), in a prospective study of 1000 consecutive patients with axillary brachial plexus block using a transarterial approach, reported an incidence of 1% of transient arterial spasm (10 of 996 patients).
We conclude that the axillary block is safe in children in the hands of experienced anesthesiologists. In this patient with a respiratory infection, general anesthesia with an endotracheal tube might have provoked a laryngospasm or bronchospasm at the time of extubation and might have been a detrimental factor in the survival of the reimplanted thumb.
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References |
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TopAbstractCase ReportDiscussionReferences |
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- Merrill DG, Brodsky JB, Hentz RV. Vascular insufficiency following axillary block of the brachial plexus. Anesth Analg 1981; 60: 162–4.
[Free Full Text] - Winnie AP. Plexus anesthesia. 1st ed. Edinburgh: Churchill Livingstone, 1984: 239.
- Lennon RL, Linstromberg JW. Brachial plexus anesthesia and axillary sheath entrance. Anesth Analg 1983; 62: 215–7.
[Abstract/Free Full Text] - Stan TC, Krantz MA, Solomon DL, et al. The incidence of neurovascular complications following axillary brachial plexus block using a transarterial approach: a prospective study of 1000 consecutive patients. Reg Anesth 1995; 20: 486–92.[Web of Science][Medline]
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