LETTERS TO THE EDITOR
Pourfour du Petit Syndrome After Supraclavicular Catheter Discontinuation Accepted for publication: May 29, 2014.
during either catheter placement because both procedures were performed with ultrasound guidance. A more likely explanation would be cervical sympathetic chain stimulation or irritation from either catheter migration or from the local anesthetic. Pourfour du Petit syndrome is a rare complication of a brachial plexus block, with only 2 cases reported in the literature. One case of PdPS occurred after a singleshot supraclavicular block done by paresthesia technique,5 and the second case was associated with a single-shot interscalene block done using nerve stimulation.6 Unlike these cases, our case is the first to be described after an ultrasound guidance technique and with a perineural catheter placement.
Improving Transversus Abdominis Plane Block Safety Accepted for publication: June 18, 2014. To the Editor: e read with interest the recent case report by Weiss et al,1 describing 2 cases of systemic local anesthetic toxicity after ultrasound-guided transversus abdominis plane (TAP) blocks for postoperative analgesia post–cesarean delivery. These cases are added to another recently described in the literature involving systemic toxicity in a patient after a cesarean delivery.2 As the authors correctly indicate, as the use of TAP blocks has increased, rare but severe complications have emerged. Based on the cases described, Weiss et al concluded that safety of the technique must be improved, using continuous ultrasound observation, pausing before the second TAP block, and using a lower concentration of local anesthetic solutions when bilateral blocks are required. Local anesthetic systemic toxicity (LAST) results from unintentionally high blood levels of free drug, due to 2 main reasons: intravascular (venous or arterial) injection of anesthetic solution and significant absorption from the injection site. Research suggests that ultrasound guidance helps prevent intravascular injections, decreasing the incidence of LAST after peripheral nerve blocks.3 Reducing the concentration of local anesthetic decreases the total mass of drug and, with it, the chances of significant plasmatic peaks after the injection. Absorption from the interfascial plane between the transversus abdominis and internal oblique muscles can be significant. It is a highly vascularized intermuscular plane where, as the authors indicate, intramuscular injection due to involuntary movements of the needle tip during the injection is quite common. How can this absorption be reduced? In this context, it is relevant to remember the recommendations for preventing LAST published by the American Society of Regional Anesthesia.4 Specifically, these recommendations state: “When injecting potentially toxic doses of local anesthetic, use of an intravascular marker is recommended.” Although an imperfect marker, the use of epinephrine in the anesthetic
To the Editor: e present the case of an adolescent who developed Pourfour du Petit syndrome (PdPS) after discontinuation of a supraclavicular catheter. The patient’s mother gave permission to publish this report. A 17-year-old adolescent girl underwent an above-the-left-elbow amputation secondary to a distal humerus osteosarcoma. Preoperatively, a supraclavicular catheter was placed without difficulty for postoperative analgesia. On postoperative day 1, the catheter was replaced because the original catheter had migrated. The new supraclavicular catheter seemed to function properly with adequate pain control, but the patient developed a left-sided Horner syndrome after an initial bolus. The catheter was removed on postoperative day 5, and within 24 hours of removal the patient developed left pupil mydriasis. The patient was evaluated by her primary care physician, who confirmed the mydriasis as well as a normal neurological examination. She was referred to an ophthalmologist, whose examination resulted in the same findings. Expectant management was followed, and the patient’s PdPS resolved spontaneously after approximately 3 months. Pourfour du Petit syndrome is a rare disorder that is classically described as Reverse Horner syndrome. The syndrome was originally described in the 18th century by the French surgeon Pourfour du Petit, and is characterized by mydriasis, eyelid retraction, and hyperhidrosis.1 Although the exact mechanism is unknown, it is thought to result from overstimulation or irritation of the cervical sympathetic chain.2 The condition has been associated with carcinomas,2 intracranial processes,3 central venous catheterization, nonpenetrating injuries of the cervical sympathetic chain and brachial plexus,4 and brachial plexus regional anesthesia.5,6 The course of PdPS is variable and may result in transient or permanent symptoms. Management includes supportive therapy for mild symptoms or a stellate ganglion block for more severe symptoms. The true etiology of our patient’s PdPS is unclear, but is most likely related to the second catheter placement. It is unlikely that the cervical sympathetic chain was injured
6. Santhosh M, Pai R, Rao R. Pourfour du Petit syndrome after interscalene block. Saudi J Anaesth. 2013;7:203–204.
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Regional Anesthesia and Pain Medicine • Volume 39, Number 5, September-October 2014
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Katherine M. Van Demark, MD Thomas A. Nicholas, MD Jennifer M. Ahlers, MD Jennifer J. Adams, MD Beth R. Burton, MD Dustin R. Ward, MD Scott C. Hofmann, MD Department of Anesthesiology University of Nebraska Medical Center Omaha, NE
The authors declare no conflict of interest. REFERENCES 1. Cole M, Berghuis J. The reverse Horner syndrome. J Thorac Cardiovasc Surg. 1970;59:603–606. 2. Martinez-Ramirez S, Roig C, Martí-Fàbregas J. Pourfour du Petit syndrome in a patient with thyroid carcinoma. Case Rep Neurol. 2010;2:96–100. 3. Nappi G, Poloni M, Bono G, Mazzella G, Bo P. Pourfour du Petit syndrome and intracranial aneurysms. Riv Patol Nerv Ment. 1976;96: 354–362. 4. Teeple E, Ferrer EB, Ghia JN, Pallares V. Pourfour du Petit syndrome—hypersympathetic dysfunctional state following a direct non-penetrating injury to the cervical sympathetic chain and brachial plexus. Anesthesiology. 1981;55:591–592. 5. Large M, Salles C, Descoins PF, Daniaud MD, Dalbon F, Coste G. Pourfour du Petit syndrome following brachial plexus block [in French]. Ann Fr Anesth Reanim. 1984;3:232–234.
W
Copyright © 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 39, Number 5, September-October 2014
solution has benefits that can outweigh its risks. This impact is not only due to its intravascular marker effect, but because it reduces the plasma levels resulting from the injections. The addition of vasoconstrictors to the anesthetic solution has proven to significantly decrease the absorption of local anesthetics and their resulting plasma concentrations in peripheral nerve blocks.5 In the case of TAP blocks, adding epinephrine to the anesthetic mixture reduces the arterial and venous plasma level concentrations compared with the use of plain local anesthetic solution.6 Considering that TAP blocks have shown to be useful in this setting, case reports such as those presented by Weiss et al force us to improve our safety measures. Maybe it is time to consider the good and old epinephrine as an adjuvant when performing TAP blocks.
Marcia A. Corvetto, MD Fernando R. Altermatt, MD, MHSc Department of Anesthesiology Escuela de Medicina Pontificia Universidad Católica de Chile Santiago, Chile
The authors declare no conflict of interest. REFERENCES 1. Weiss E, Jolly C, Dumoulin JL, et al. Convulsions in 2 patients after bilateral ultrasound-guided transversus abdominis plane blocks for cesarean analgesia. Reg Anesth Pain Med. 2014;39:248–251. 2. Naidu RK, Richebé P. Probable local anesthetic systemic toxicity in a postpartum patient with acute fatty liver of pregnancy after a transversus abdominis plane block. A&A Case Rep. 2013;1:72–74.
“Wrong Side” Sticker/Dressing to Help Reduce Wrong-Sided Nerve Blocks Accepted for publication: May 27, 2014. To the Editor: e read “A checklist for performing regional nerve blocks” by Mulroy et al1 with great interest. With peripheral nerve blocks at an all-time high since the introduction of ultrasound, it is unsurprising that there are more and more wrongsided nerve blocks being reported. Their incidence has not been reduced by the World Health Organization Surgical Safety Checklist,2 which focuses primarily on wrong-site surgery rather than anesthetic-related procedures, or the use of the Universal Protocol3 in the United States. The introduction of new measures specific to regional nerve blocks may be needed to reduce the incidence of wrongsided nerve blocks. There is little in the medical literature identifying their incidence, with most reports being in the lay press. Recent surveys in the North Western Deanery in the United Kingdom show that 40 (26.3%) of 152 respondents (2010)4 and 75 (30.7%) of 244 (2012)5 had been involved in wrong-sided nerve blocks. The main contributors to wrongsided nerve blocks include a lack of a formal, consistent check system specific for anesthetic procedures, overreliance on site marking done by surgeons, procedural factors including the change of theater lists,
W
Letters to the Editor
position of the patients, time pressure, false sense of security with awake patients,6 and the use of the surgical consent form for final check. We have introduced into our practice a “Wrong Side” sticker measuring 4.5 cm in diameter on a nonallergenic dressing. The sticker is to be placed on the nonoperative side, opposite the block location (Fig. 1). This sticker/dressing serves as a physical barrier to stop us from preparing and needling the wrong side, acting as a double reinforcement in addition to existing surgical site marking. We have involved patients in placing these stickers before the nerve block and induction in the anesthetic room and have found that patients welcome the reassurance given. Many measures have been suggested in the past to prevent wrong-sided nerve blocks, but despite these, the incidence is on the rise. Although it may not be possible to eliminate all human factors, we must continue to find ways to reduce the frequency of wrong-sided blocks. We have found that our simple “Wrong Side” sticker is easy and quick to apply and provides a physical barrier to stop the anesthetist from preparing and needling the wrong side.
Jason Lie, FRCA Specialty Trainee (ST6) North Western Deanery United Kingdom
Martin Letheren, FRCA Lancashire Teaching Hospitals NHS Foundation Trust, Preston United Kingdom
The authors declare no conflict of interest.
3. Barrington MJ, Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013;38: 289–297. 4. Neal JM, Bernards CM, Butterworth JF 4th, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35:152–161. 5. Karmakar MK, Ho AMH, Law BK, Wong ASY, Shafer SL, Gin T. Arterial and venous pharmacokinetics of ropivacaine with and without epinephrine after thoracic paravertebral block. Anesthesiology. 2005;103:704. 6. Corvetto MA, Echevarria GC, La Fuente De N, Mosqueira L, Solari S, Altermatt F. Comparison of plasma concentrations of levobupivacaine with and without epinephrine for transversus abdominis plane block. Reg Anesth Pain Med. 2012;37:633–637.
FIGURE 1. A picture showing our “Wrong Side” sticker on top of a non-allergenic dressing (paperclip for size comparison).
© 2014 American Society of Regional Anesthesia and Pain Medicine
441
Copyright © 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Pourfour du Petit Syndrome After Supraclavicular Catheter Discontinuation Accepted for publication: May 29, 2014.
during either catheter placement because both procedures were performed with ultrasound guidance. A more likely explanation would be cervical sympathetic chain stimulation or irritation from either catheter migration or from the local anesthetic. Pourfour du Petit syndrome is a rare complication of a brachial plexus block, with only 2 cases reported in the literature. One case of PdPS occurred after a singleshot supraclavicular block done by paresthesia technique,5 and the second case was associated with a single-shot interscalene block done using nerve stimulation.6 Unlike these cases, our case is the first to be described after an ultrasound guidance technique and with a perineural catheter placement.
Improving Transversus Abdominis Plane Block Safety Accepted for publication: June 18, 2014. To the Editor: e read with interest the recent case report by Weiss et al,1 describing 2 cases of systemic local anesthetic toxicity after ultrasound-guided transversus abdominis plane (TAP) blocks for postoperative analgesia post–cesarean delivery. These cases are added to another recently described in the literature involving systemic toxicity in a patient after a cesarean delivery.2 As the authors correctly indicate, as the use of TAP blocks has increased, rare but severe complications have emerged. Based on the cases described, Weiss et al concluded that safety of the technique must be improved, using continuous ultrasound observation, pausing before the second TAP block, and using a lower concentration of local anesthetic solutions when bilateral blocks are required. Local anesthetic systemic toxicity (LAST) results from unintentionally high blood levels of free drug, due to 2 main reasons: intravascular (venous or arterial) injection of anesthetic solution and significant absorption from the injection site. Research suggests that ultrasound guidance helps prevent intravascular injections, decreasing the incidence of LAST after peripheral nerve blocks.3 Reducing the concentration of local anesthetic decreases the total mass of drug and, with it, the chances of significant plasmatic peaks after the injection. Absorption from the interfascial plane between the transversus abdominis and internal oblique muscles can be significant. It is a highly vascularized intermuscular plane where, as the authors indicate, intramuscular injection due to involuntary movements of the needle tip during the injection is quite common. How can this absorption be reduced? In this context, it is relevant to remember the recommendations for preventing LAST published by the American Society of Regional Anesthesia.4 Specifically, these recommendations state: “When injecting potentially toxic doses of local anesthetic, use of an intravascular marker is recommended.” Although an imperfect marker, the use of epinephrine in the anesthetic
To the Editor: e present the case of an adolescent who developed Pourfour du Petit syndrome (PdPS) after discontinuation of a supraclavicular catheter. The patient’s mother gave permission to publish this report. A 17-year-old adolescent girl underwent an above-the-left-elbow amputation secondary to a distal humerus osteosarcoma. Preoperatively, a supraclavicular catheter was placed without difficulty for postoperative analgesia. On postoperative day 1, the catheter was replaced because the original catheter had migrated. The new supraclavicular catheter seemed to function properly with adequate pain control, but the patient developed a left-sided Horner syndrome after an initial bolus. The catheter was removed on postoperative day 5, and within 24 hours of removal the patient developed left pupil mydriasis. The patient was evaluated by her primary care physician, who confirmed the mydriasis as well as a normal neurological examination. She was referred to an ophthalmologist, whose examination resulted in the same findings. Expectant management was followed, and the patient’s PdPS resolved spontaneously after approximately 3 months. Pourfour du Petit syndrome is a rare disorder that is classically described as Reverse Horner syndrome. The syndrome was originally described in the 18th century by the French surgeon Pourfour du Petit, and is characterized by mydriasis, eyelid retraction, and hyperhidrosis.1 Although the exact mechanism is unknown, it is thought to result from overstimulation or irritation of the cervical sympathetic chain.2 The condition has been associated with carcinomas,2 intracranial processes,3 central venous catheterization, nonpenetrating injuries of the cervical sympathetic chain and brachial plexus,4 and brachial plexus regional anesthesia.5,6 The course of PdPS is variable and may result in transient or permanent symptoms. Management includes supportive therapy for mild symptoms or a stellate ganglion block for more severe symptoms. The true etiology of our patient’s PdPS is unclear, but is most likely related to the second catheter placement. It is unlikely that the cervical sympathetic chain was injured
6. Santhosh M, Pai R, Rao R. Pourfour du Petit syndrome after interscalene block. Saudi J Anaesth. 2013;7:203–204.
440
Regional Anesthesia and Pain Medicine • Volume 39, Number 5, September-October 2014
W
Katherine M. Van Demark, MD Thomas A. Nicholas, MD Jennifer M. Ahlers, MD Jennifer J. Adams, MD Beth R. Burton, MD Dustin R. Ward, MD Scott C. Hofmann, MD Department of Anesthesiology University of Nebraska Medical Center Omaha, NE
The authors declare no conflict of interest. REFERENCES 1. Cole M, Berghuis J. The reverse Horner syndrome. J Thorac Cardiovasc Surg. 1970;59:603–606. 2. Martinez-Ramirez S, Roig C, Martí-Fàbregas J. Pourfour du Petit syndrome in a patient with thyroid carcinoma. Case Rep Neurol. 2010;2:96–100. 3. Nappi G, Poloni M, Bono G, Mazzella G, Bo P. Pourfour du Petit syndrome and intracranial aneurysms. Riv Patol Nerv Ment. 1976;96: 354–362. 4. Teeple E, Ferrer EB, Ghia JN, Pallares V. Pourfour du Petit syndrome—hypersympathetic dysfunctional state following a direct non-penetrating injury to the cervical sympathetic chain and brachial plexus. Anesthesiology. 1981;55:591–592. 5. Large M, Salles C, Descoins PF, Daniaud MD, Dalbon F, Coste G. Pourfour du Petit syndrome following brachial plexus block [in French]. Ann Fr Anesth Reanim. 1984;3:232–234.
W
Copyright © 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 39, Number 5, September-October 2014
solution has benefits that can outweigh its risks. This impact is not only due to its intravascular marker effect, but because it reduces the plasma levels resulting from the injections. The addition of vasoconstrictors to the anesthetic solution has proven to significantly decrease the absorption of local anesthetics and their resulting plasma concentrations in peripheral nerve blocks.5 In the case of TAP blocks, adding epinephrine to the anesthetic mixture reduces the arterial and venous plasma level concentrations compared with the use of plain local anesthetic solution.6 Considering that TAP blocks have shown to be useful in this setting, case reports such as those presented by Weiss et al force us to improve our safety measures. Maybe it is time to consider the good and old epinephrine as an adjuvant when performing TAP blocks.
Marcia A. Corvetto, MD Fernando R. Altermatt, MD, MHSc Department of Anesthesiology Escuela de Medicina Pontificia Universidad Católica de Chile Santiago, Chile
The authors declare no conflict of interest. REFERENCES 1. Weiss E, Jolly C, Dumoulin JL, et al. Convulsions in 2 patients after bilateral ultrasound-guided transversus abdominis plane blocks for cesarean analgesia. Reg Anesth Pain Med. 2014;39:248–251. 2. Naidu RK, Richebé P. Probable local anesthetic systemic toxicity in a postpartum patient with acute fatty liver of pregnancy after a transversus abdominis plane block. A&A Case Rep. 2013;1:72–74.
“Wrong Side” Sticker/Dressing to Help Reduce Wrong-Sided Nerve Blocks Accepted for publication: May 27, 2014. To the Editor: e read “A checklist for performing regional nerve blocks” by Mulroy et al1 with great interest. With peripheral nerve blocks at an all-time high since the introduction of ultrasound, it is unsurprising that there are more and more wrongsided nerve blocks being reported. Their incidence has not been reduced by the World Health Organization Surgical Safety Checklist,2 which focuses primarily on wrong-site surgery rather than anesthetic-related procedures, or the use of the Universal Protocol3 in the United States. The introduction of new measures specific to regional nerve blocks may be needed to reduce the incidence of wrongsided nerve blocks. There is little in the medical literature identifying their incidence, with most reports being in the lay press. Recent surveys in the North Western Deanery in the United Kingdom show that 40 (26.3%) of 152 respondents (2010)4 and 75 (30.7%) of 244 (2012)5 had been involved in wrong-sided nerve blocks. The main contributors to wrongsided nerve blocks include a lack of a formal, consistent check system specific for anesthetic procedures, overreliance on site marking done by surgeons, procedural factors including the change of theater lists,
W
Letters to the Editor
position of the patients, time pressure, false sense of security with awake patients,6 and the use of the surgical consent form for final check. We have introduced into our practice a “Wrong Side” sticker measuring 4.5 cm in diameter on a nonallergenic dressing. The sticker is to be placed on the nonoperative side, opposite the block location (Fig. 1). This sticker/dressing serves as a physical barrier to stop us from preparing and needling the wrong side, acting as a double reinforcement in addition to existing surgical site marking. We have involved patients in placing these stickers before the nerve block and induction in the anesthetic room and have found that patients welcome the reassurance given. Many measures have been suggested in the past to prevent wrong-sided nerve blocks, but despite these, the incidence is on the rise. Although it may not be possible to eliminate all human factors, we must continue to find ways to reduce the frequency of wrong-sided blocks. We have found that our simple “Wrong Side” sticker is easy and quick to apply and provides a physical barrier to stop the anesthetist from preparing and needling the wrong side.
Jason Lie, FRCA Specialty Trainee (ST6) North Western Deanery United Kingdom
Martin Letheren, FRCA Lancashire Teaching Hospitals NHS Foundation Trust, Preston United Kingdom
The authors declare no conflict of interest.
3. Barrington MJ, Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Reg Anesth Pain Med. 2013;38: 289–297. 4. Neal JM, Bernards CM, Butterworth JF 4th, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35:152–161. 5. Karmakar MK, Ho AMH, Law BK, Wong ASY, Shafer SL, Gin T. Arterial and venous pharmacokinetics of ropivacaine with and without epinephrine after thoracic paravertebral block. Anesthesiology. 2005;103:704. 6. Corvetto MA, Echevarria GC, La Fuente De N, Mosqueira L, Solari S, Altermatt F. Comparison of plasma concentrations of levobupivacaine with and without epinephrine for transversus abdominis plane block. Reg Anesth Pain Med. 2012;37:633–637.
FIGURE 1. A picture showing our “Wrong Side” sticker on top of a non-allergenic dressing (paperclip for size comparison).
© 2014 American Society of Regional Anesthesia and Pain Medicine
441
Copyright © 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
