A total spinal block: A rare but life-threatening complication of thoracic paravertebral block

Dear Editor, Thoracic paravertebral block (TPVB) produces unilateral, segmental, somatic, and sympathetic blocks, which are effective for acute as well as chronic pain of unilateral origin from the chest and abdomen.[1] Here, we report a case of total spinal anaesthesia following a TPVB during modified radical mastectomy (MRM) surgery. A 40-year-old female, weighing 60 kg and 160 cm in height, diagnosed with right-sided breast carcinoma, was posted for MRM. The patient belongs to the American Society of Anaesthesiologists (ASA) physical class II. She had a known case of Diabetes mellitus (DM) for five years and was on irregular medication; her fasting blood glucose was 140 mg/dl, and postprandial was 200 mg/dl. The rest of the investigations (electrocardiography (ECG), X-ray chest) were within normal limits. After taking informed and written consent, the patient was wheeled into the operating room; all the ASA standard monitors were applied. The patient was conscious, oriented, and following verbal commands; vitals were within normal range. It was planned to administer TPVB with 15 ml of 0.25% bupivacaine for analgesia, followed by General anaesthesia. The patient was made to sit for TPVB by landmark-based technique at the T4-T5 level. While administering the block, upon completion of 5 ml of local anaesthetic (LA), the patient was found to be unresponsive and not obeying commands. The patient was immediately placed in a supine position, and her vitals were as follows: heart rate of 84/min, blood pressure of 80/40 mm Hg, oxygen saturation (SpO2) −80%, ECG on the monitor was within normal limits, bilateral pupils were dilated and non-responsive to light. Immediately, bag and mask ventilation was started with 100% oxygen; hypotension was managed with fluid boluses (0.9% normal saline) and vasopressors (mephentermine boluses of 6 mg IV); the hypoglycaemic event was ruled out as random blood sugar (RBS) was 106 mg/dl. The definitive airway was secured with endotracheal intubation and put on mechanical ventilation as the patient continued to be unresponsive and apneic. The non-contrast computer tomography (NCCT) of the brain, done to rule out any cerebrovascular event, was normal. The patient regained consciousness with spontaneous respiration after 2–3 h after the incident and started obeying the commands, and was extubated; the surgery was rescheduled after 2 days. A total spinal block is a rare but life-threatening complication that can occur during the injection of LA close to the neuraxis (e.g., spinal, epidural anaesthesia, paravertebral block, stellate ganglion block, etc.). It may occur due to an inexperienced hand, direct injection into the neural tissue, blind technique, use of a high volume of LA, or cephalad spread of the drug. Manifested as hypotension, nausea, vomiting, bradycardia, apnoea, respiratory distress, paraesthesia, dysaesthesia, areflexia, cranial nerve involvement, and cardiac arrest.[2] Beyaz et al.[2] reported a case of total spinal block after TPVB in a 63-year-old female posted for open cholecystectomy. It was given at T7 under the guidance of ultrasound and a nerve locator. Lekhak et al.[3] also reported a total spinal block after thoracic PVB in a 62-year-old female who underwent thoracotomy. The patient developed hypotension, apnea, and unconsciousness, which occurred due to an unintended subarachnoid injection. But recovered after 2 h, but the extremity weakness continued for several hours. The patient was discharged without any neurological sequelae. Symptomatic treatment remains the mainstay of management of total spinal block.[2,3] Early recognition and management of symptoms can prevent neurological sequelae. Hypotension is treated by replacing fluids and vasopressors, and bradycardia is treated using vagolytics and sympathomimetic agents. Respiratory distress with oxygen supplementation and advanced airway management. This rare complication can be avoided by using ultrasound-guided techniques, using a minimum possible dose of the agents, directing the tip of the catheter in a caudal direction, and giving intermittent doses after aspiration. The total spinal block is a rare but life-threatening complication of the thoracic paravertebral block that, if not recognised and treated promptly, may lead to neurological and cardiorespiratory sequelae. it can be easily prevented and managed using appropriate airway breathing and cardiac support. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.