Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942006000500010
Brazilian Journal of Anesthesiology
Clinical Information

Raquianestesia total após bloqueio do plexo lombar por via posterior: relato de caso

Total spinal block after posterior lumbar plexus blockade: case report

Leonardo Teixeira Domingues Duarte; Renato Ângelo Saraiva

http://dx.doi.org/10.1590/S0034-70942006000500010 Braz J Anesthesiol, vol.56, n5, p.518-523, 2006
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Resumo

JUSTIFICATIVA E OBJETIVOS: O bloqueio do plexo lombar pode ser bastante útil em procedimentos cirúrgicos do quadril, da coxa e do joelho, mas exige prática do anestesiologista tendo em vista suas potenciais complicações. O presente relato tem por objetivo apresentar um caso de raquianestesia total após bloqueio do plexo lombar pela via posterior e discutir o provável mecanismo fisiopatológico. RELATO DO CASO: Paciente do sexo masculino, 34 anos, 97 kg, estado físico ASA I, programado para artroplastia total do quadril. Foi realizada anestesia geral seguida de bloqueio do plexo lombar direito pela via posterior com auxílio de estimulador de nervo periférico. A agulha foi introduzida até uma profundidade de 8 cm, perpendicular à pele, e a uma distância de 4 cm da linha média sobre uma linha perpendicular ao processo espinhoso de L4. Após a identificação de resposta motora no quadríceps, a intensidade da corrente de estimulação foi reduzida até 0,35 mA, sendo, então, administrada ropivacaína a 0,5% (39 mL). Durante a injeção, foram verificadas contrações intermitentes do quadríceps. Após o bloqueio, o paciente evoluiu com apnéia, hipotensão arterial e midríase bilateral. Ao final da intervenção cirúrgica, apresentava bloqueio motor em ambos os membros inferiores que só regrediu após nove horas. No pós-operatório, o paciente queixou-se de dor intensa, recebendo alta hospitalar em 12 dias sem anormalidade motora ou sensitiva. CONCLUSÕES: A identificação do compartimento do psoas, onde está o plexo lombar, exige a utilização de intensidade de corrente entre 0,5 e 1 mA. A ocorrência de resposta motora com baixas correntes pode indicar posicionamento da agulha dentro da bainha que envolve a raiz nervosa e que continua até os espaços peridural e subaracnóideo, para onde a solução anestésica pode se dispersar. Apesar de oferecer larga margem de segurança, o bloqueio do plexo lombar exige do anestesiologista conhecimento minucioso da anatomia, treinamento na técnica e vigilância constante.

Palavras-chave

ANESTESIA, Regional, COMPLICAÇÕES

Abstract

BACKGROUND AND OBJECTIVES: Lumbar plexus blockade can be very useful in surgical procedures of the hip, thigh, and knee, but it should be performed by an experienced anesthesiologist due to potential complications. The current report presents a case of total spinal block after posterior lumbar plexus blockade and discusses the possible pathophysiological mechanisms. CASE REPORT: Male patient, 34 years old, 97 kg, physical status ASA I, scheduled for total hip arthroplasty. After general anesthesia, a right posterior lumbar plexus blockade was performed with the adjunct of a peripheral nerve stimulator. The needle was introduced to a depth of 8 cm, perpendicular to the skin, 4 cm from the mid line, on a line perpendicular to the spinal process of L4. After identification of a motor response from the quadriceps, the intensity of the current was reduced to 0.35 mA and 0.5% ropivacaine (39 mL) was administered. During the injection, there were intermittent contractions of the quadriceps. After the block, the patient presented apnea, hypotension, and both pupils were dilated. At the end of the surgery, the patient presented motor block of the lower extremities, which reversed only nine hours after the block. In the postoperative period, the patient complained of severe pain; he was discharged 12 days after the surgery without motor or sensitive deficits. CONCLUSIONS: To identify the psoas compartment, where the lumbar plexus blockade is located, the intensity of the current must be between 0.5 and 1 mA. Motor response with low current indicates that the needle may be inside the sheath that surrounds the nervous root and extends to the epidural and subarachnoid spaces, to where the anesthetic solution might spread. Despite the wide safety margin of the procedure, the anesthesiologist must have keen anatomy knowledge, training on the technique, and be constantly alert to perform a lumbar plexus blockade.

Keywords

ANESTHESIA, Regional, COMPLICATIONS

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