1900 LETTERS TO THE EDITOR ANESTH ANALG

2006;102:1899 –1913

We attributed this burn to the multiple transthoracic DC coun-
tershocks. The defibrillator was tested and found to be working
properly. We could not assess myocardium damage from the defi-
brillation. We removed the pulmonary artery catheter 3 days after
the last countershock, and we had not sampled enzymes in the
intervening period.
The burn in the pulmonary artery catheter suggests that biphasic
countershock produces considerable heat, which might further
damage an already diseased heart.
Munish Sharma, MD, DNB, MNAMS
Kartikeya Bhargava, MD, DNB (Cardiology)
Yatin Mehta, MD, DNB, FRCA, FAMS
Naresh Trehan, MD
Escorts Heart Institute and Research Centre
New Delhi, India
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by injecting 2–3 mL of 2% lidocaine hydrochloride (Xylocaine; Astra
Zeneca, Södertälje, Sweden) into the retrobulbar space. Subconjunc-
tival anesthesia was performed by slow injection of 0.5–1 mL of 2%
lidocaine into the subconjunctival space. We recorded the following
variables: visual analog scale-intraoperative pain (VAS-OP) rated on
a 100-mm VAS, injection pain score (VAS-IN), surgeon satisfaction
score (VAS-SS), operative time, injection and operative complica-
tions, and rate of rescue medication (additional superior subcon-
junctival 2% lidocaine) use. Confidence intervals of VAS differences
were compared with ⫾10 mm equivalence range. Student’s t-test
and Fisher’s exact test were used for the other variables.
A total of 141 patients completed the study. The median differ-
ences of VAS-OP and VAS-IN were 0 mm (95% confidence interval,
⫺8 to 5 mm), and 0 mm (95% confidence interval, ⫺1 to 3 mm),
respectively. The mean difference of VAS-SS was 11.4 mm (95%
confidence interval, 8.4 to 14.4 mm) indicating surgeon preference

yatinmehta@hotmail.com
yatinmehta@gmail.com for retrobulbar anesthesia. There was no difference in surgical time,
References but the incidence of complications and use of rescue medications
1. Reddy RK, Gleva MJ, Gliner BE et al. Biphasic transthoracic defibrillation causes fewer differed significantly. Localized subconjunctival hemorrhage was
ECG ST segment changes after shock. Ann Emerg Med 1997;30:127–34. seen in 23% of the subconjunctival anesthesia cases. Rescue medi-
2. Jones JL, Jones RE. Decreased defibrillator induced dysfunction with biphasic rectan- cations were required in 18% of the retrobulbar anesthesia cases but
gular waveforms. Am J Physiol 1984;247:792– 6.
only 3% of the subconjunctival anesthesia cases (Table 1). We con-
cluded that subconjunctival anesthesia provides equivalent pain
control to retrobulbar anesthesia during extracapsular cataract ex-
traction with intraocular lens implantation. Self-limited complica-
Circumferential Subconjunctival Anesthesia tions were more frequent in the group anesthetized with subcon-
Versus Retrobulbar Anesthesia for junctival anesthesia.
Wasee Tulvatana, MD, MSc
Extracapsular Cataract Extraction Kittisak Kulvichit, MD, MSc
To the Editor: Uraiwan Tinnungwattana, MD
Department of Ophthalmology
Retrobulbar anesthesia produces good pain control during extra- Faculty of Medicine
capsular cataract extraction with intraocular lens implantation; Chulalongkorn University
however, serious complications may occur (1–3). Circumferential Bangkok, Thailand
subconjunctival anesthesia has fewer potential complications and wasee.t@chula.ac.th
has also been proven effective (4 –5). We conducted an equivalence
trial to compare the pain control during extracapsular cataract ex- References
traction with intraocular lens implantation between retrobulbar an- 1. Edge KR, Nicoll JM. Retrobulbar hemorrhage after 12,500 retrobulbar blocks. Anesth
esthesia and subconjunctival anesthesia techniques. The trial was Analg 1993;76:1019 –22.
randomized and the patients, surgeon, and investigators were un- 2. Edge R, Navon S. Scleral perforation during retrobulbar and peribulbar anesthesia: risk
factors and outcome in 50,000 consecutive injections. J Cataract Refract Surg 1999;25:
aware of treatment group. Retrobulbar anesthesia was performed 1237– 44.
3. Nicoll JM, Acharya PA, Ahlen K, et al. Central nervous system complications after 6000
retrobulbar blocks. Anesth Analg 1987;66:1298 –302.
4. Redmond RM, Dallas NL. Extracapsular cataract extraction under local anaesthesia
without retrobulbar injection. Br J Ophthalmol 1990;74:203– 4.
Table 1. Patient Characteristics and Results 5. Makuloluwa CA, Dharmarathna L. Circumcorneal perilimbal anesthesia in extracap-
sular cataract extraction with intraocular lens implantation. J Cataract Refract Surg
Retrobulbar Subconjunctival 2000;26:1647–9.
anesthesia anesthesia
(n ⫽ 79) (n ⫽ 79) P value
Age, y 66.3 ⫾ 10.8 68.7 ⫾ 13.0
Male patients 40 (50.6) 25 (40.3) Paraplegia After Spinal Anesthesia as a
Right eye operation 37 (46.8) 35 (56.5)
First eye operation 63 (79.7) 54 (87.1) Result of Previously Undiagnosed Vertebral
Operative time, min 12.5 ⫾ 2.9 13.0 ⫾ 4.4 0.51 Tuberculosis
VAS-OP, mm 10 [5, 50] 20 [8.5, 40]
VAS-IN, mm 7 [3, 20] 10 [1, 15] To the Editor:
VAS-SS, mm 79 ⫾ 8.4 68 ⫾ 9.6
Spinal anesthesia is a safe, routinely performed procedure (1). Per-
Injection complications <0.001
manent neurological injury is rare, but transient injuries are more
None 78 48
commonly reported (0.01%-0.08%) (2). We report an interesting case
Localized 0 14
of an elderly man with paraplegia after spinal anesthesia as a result
subconjunctival
of previously undiagnosed vertebral tuberculosis.
hemorrhage
An 83-yr-old man with benign prostatic hyperplasia was admit-
Partial retrobulbar 1 0
ted to our hospital for treatment of his urinary retention. His med-
hemorrhage
ical history was significant for hypertension, chronic obstructive
Operative complications 0.44
lung disease, hyperplastic thyroid gland, and mild coronary artery
None 79 61
disease. After applying monitors the patient was placed in a lateral
Suprachoroidal 0 1
decubitus position, and a spinal anesthetic was performed in one
hemorrhage
attempt using a 25-gauge Quincke spinal needle in the L5-S1 in-
Rescue medication use 14 (17.7) 2 (3.2) 0.007
terspace. Hyperbaric bupivacaine (2.5 mL, 0.5%), was injected into
Values are mean ⫾ sd, median [interquartile range] or n (%). VAS ⫽ visual the subarachnoid space. Transient hypotension followed and was
analog scale; OP ⫽ intraoperative pain; IN ⫽ injection pain; SS ⫽ satisfaction treated with 15 mg of ephedrine, and he was hemodynamically
score. stable thereafter.
ANESTH ANALG LETTERS TO THE EDITOR 1901
2006;102:1899 –1913

References
1. Wenger M, Hauswirth CB, Brodhage RP. Undiagnosed adult diastematomyelia asso-
ciated with neurological symptoms following spinal anaesthesia. Anaesthesia 2001;56:
764 –7.
2. Faccenda KA, Finucane BT. Complications of regional anaesthesia Incidence and
prevention. Drug Saf 2001;24:413– 42.
3. Mutoh S, Aikou I, Ueda S. Spinal coning after lumbar puncture in prostate cancer with
asymptomatic vertebral metastasis: a case report. J Urol 1991;145:834 –5.
4. Hyderally HA Epidural hematoma unrelated to combined spinal-epidural anesthesia
in a patient with ankylosing spondylitis receiving aspirin after total hip replacement.
Anesth Analg. 2005;100:882–3.
5. De Tommaso O, Caporuscio A, Tagariello V. Neurological complications following
central neuraxial blocks: are there predictive factors? Eur J Anaesthesiol 2002;19:705–
16.

Emergent Facial Lacerations Repair in

Children: Nerve Blocks to the Rescue!
To the Editor:
Infraorbital nerve block can provide postoperative analgesia for
procedures involving the upper lip and vermilion (e.g., cleft lip
repair) (1) and nasal surgery (e.g., septal reconstruction, rhino-
plasty, and endoscopic sinus surgery) (2). We performed this block
on a 2-yr-old girl who presented with severe facial laceration in-
volving the philtrum and the maxillary area (Fig. 1). After informed
consent was obtained from her parents and induction of general
anesthesia, infraorbital nerve blocks were performed using an in-
traoral approach. The infraorbital foramen was palpated, the upper
lid was everted, and a 27-gauge needle was advanced using a
subsulcal approach towards the infraorbital foramen. One mL of
Figure 1. Sagittal T1-weighted magnetic resonance imaging scan 0.25% bupivacaine with 1:200,000 epinephrine was injected after
after IV gadolinium contrast injection showing a lesion with periph- aspiration on each side. Postoperatively she was pain-free and
eral contrast enhancement between T4 and T6 that compresses the required no rescue pain medication for more than 48 hours. On
spinal cord. follow-up for suture removal the parents reported complete satis-
faction with the postoperative course.
Infraorbital nerve block is an excellent option for postoperative
Thirty-six hours after the operation, numbness continued, and a pain control for facial trauma involving the upper lip and inframax-
physical examination showed freely movable extremities with rel- illary area. Bilateral injections can provide excellent pain relief with-
ative weakness in the lower extremity. Muscle strength was 3/5 on out the side effects of systemic opioids.
his left leg and 2/5 on his right leg, and there was poor response to
Stefan Budac, MD
pain and sensory stimulus. Neurologic assessment revealed sensory
Department of Anesthesiology
loss below the first thoracic vertebrae. An emergency magnetic Rush Medical Center
resonance imaging scan of the lumbar region was performed to Chicago, IL
exclude an epidural hematoma. The lumbar magnetic resonance stefan_budac@rush.edu
imaging scan revealed no pathological findings. An emergent tho-
racic magnetic resonance imaging scan demonstrated a mass ex-
tending from T4 to T6 compressing the spinal cord. (Fig. 1) A
computed tomography-guided biopsy showed granulomatous in-
flammation with calcification, consistent with Pott’s disease. The
diagnosis was confirmed by microbiological studies.
Spinal tumors can cause acute neurologic deterioration after lum-
bar puncture. This phenomenon is related to traction on the spinal
cord induced by cerebrospinal fluid pressure differences (3). The
same phenomenon might have been responsible for our patient’s
neurologic symptoms after spinal anesthesia. Another possibility
might be development of spinal infarct after spinal anesthesia. We
recommend that clinicians perform neurological evaluations of all
candidates for regional anesthesia and inform them about potential
complications (2). Another important concept is that postoperative
neurologic examinations after neuraxial blocks should be routinely
performed (4). Monitoring of patients receiving epidural or spinal
blocks that extend into the postoperative period should include
regular assessment until full return of neurological function (5).
Pelin Karaaslan, MD
Selim Candan, MD
Department of Anesthesiology
pelink@baskent-ank.edu.tr
Ceyla Basaran, MD
Department of Radiology
Baskent University School of Medicine Figure 1. Block for severe facial laceration involving the philtrum
Ankara, Turkey and the maxillary area.