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Inadvertent Brainstem Anesthesia

Inadvertent Brainstem Anesthesia

“Subsequently, on a quick glance of the EKG, the anesthesia provider realized the patient was bradycardic and apneic.”

Case Context   Provider Narrative Background Lessons Learned

Case Context

Patient: middle-aged adult
Diagnosis: detached retina
Procedure: vitrectomy
PMH: NKDA, ASA II, with hypertension, controlled with medication, obesity 100 kg, BMI 35 kg/m2
Medications: multivitamin  metoprolol
Anesthestic plan: General anesthesia, ETT

Provider Narrative

The patient was initially seen in the preoperative holding area where he was assessed. He had a normal airway evaluation and reported taking medication for hypertension but said he was “otherwise healthy.”

Soon after the evaluation, EKG, NIBP and pulse oximetry monitors were placed, etCO2 monitoring was not available for use. The patient was placed on oxygen 4 L/min NC and given midazolam 2 mg, fentanyl 50 mcg and 50 mg propofol IV by the anesthesia provider in preparation for the retrobulbar block placement, which was performed by the surgeon. After the block was performed, it was evaluated as effective and the monitors were removed.

The patient was transferred to OR and reconnected to the EKG, NIBP and pulse oximetry monitors. The anesthesia provider recognized the absence of a pulse oximetry waveform and switched the probe out for a new one. Subsequently, on a quick glance of the EKG, the anesthesia provider realized the patient was bradycardic and apneic. Immediately, mask ventilation and chest compressions were initiated and the airway was secured with an endotracheal tube.

Resuscitation efforts resulted in the return of spontaneous circulation and the patient began to move, but with neurological deficits. He was taken to the post-operative recovery room for stabilization and eventually was transferred to emergency room and then admitted to the intensive care unit with a diagnosis of anoxic encephalopathy. The patient was discharged within a week but continued to experience residual memory loss.


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