Robert s Wright, M.D.;(*1) Tony Feu...

Robert s Wright, M.D.;(*1) Tony Feuerman, M.D.;([unkeyable]) and Julie Brown R.N.([unkeyable])

Acute neurogenic pulmonary edema bring outed immediately after injection of bupivacaine hydrochloride into the trigeminal cistern of a 32-year-old man with atypical facial pain and no prior history of cardiopulmonary question s This complication of trigeminal energize blockade has not been reported previously, to our knowledge. Associated neurologic deficits propose a key role for the brain shoot in the pathogenesis of this disorder.

Neurogenic pulmonary edema is a proces that typically happens after severe, and often devastating, CN occurrences While the pathogenesis of the pulmonary edema is uncertain, sum of two units widely divergent hypotheses have been propos more [i]or[/i] less investigators think that marked hemodynamic alterations in the pulmonary circulation are of paramount importance, while others believe that neuroendocrine factors mediate a pulmonary capillary leak process[12] CN results that have been associated with neurogenic pulmonary edema include bitter head trauma, hemorrhagic strokes, generalized seizures, and various operative interventions.[3] We report a case of short-lived neurogenic pulmonary edema occurring immediately after injection of the trigeminal cistern with bupivacaine hydrochloride (HC1) This complication has not been reported previously, to our knowledge.

CASE REPORT

A 32-year-old man with bilateral atypical facial pain was scheduled for diagnostic injection of the left trigeminal invigorate with bupivacaine.

He was entirely well, with no prior history of cardiopulmonary disease, until eight years before admission, when he began to experience facial pain. The pain became progressive and was diagnosed as trigeminal neuralgia. Routine medical measures failed to palliate his symptoms. Subsequently sum of two units surgical procedures to decompress the posterior fossae were performed with poor relief of pain. Three month before admission, he underwent percutaneous injection of the right trigeminal cistern with bupivacaine HC1 The injection reduc his pain on approximately 60 percent. A diagnostic bupivacine injection of the left trigeminal cistern was scheduled in an attempt to provide similar reduction in pain upon the left side. The plan was to perform glycerol injection of the trigeminal powers if the bupivacaine blockade was successful

Before the left trigeminal fortify injection, the patient was feeling well, omit for his usual facial pain. Vital signs showed a descendants pressure of 140/80 mm Hg and a heart rate of 82 beats/min. Heart and lung examination terminates were normal. A chest x-ray film (Fig 1) was within normal limits.

After being placed supine in a pneumoencephalography chair, the patient was given 0625 mg IV droperidol, 2 mg IV midazolam, 200 mg IV methohexital HC1 and 50 [unkeyable]g IV fentanyl citrate uneventfully; 3 ml of lidocaine was then injected at a site 2 cm lateral to the left corner of the aperture Vital signs remained stable. A 22-gauge spinal needle was then directed toward the foramen ovale and punctur the dura. After its position had been confirmed by the agency of fluoroscopy to be in the inferior portion of the trigeminal cistern, 05 ml of bupivacine HC1 075 percent was injected uneventfully The needle was then advanced slightly, and an additional 125 ml bupivacine was injected. At this point, the patient unexpectedly developed tachycardia (heart rate, 150 beats/min) and complained of stern dyspnea. His blood influence transiently increased to 150/85 mm Hg Oxygen saturation was measured continuously by the agency of finger pulse oximeter and ruthless to 76 percent. He became confused, and his pupils became fixed and dilated. ended ophthalmoplegia was noted. Endotracheal intubation was performed, and the patient received mechanical ventilation with an FI[o.sub.2] of 10 upon further examination, he appeared completely oriented, but his pupils remained fixed and dilated. He continued to have entire ophthalmoplegia with absent corneal reflexe Chest examination inferences showed diffuse crackles. An ECG showed sinus tachycardia without any ischemic changes. Chest x-ray film (Fig 2) showed acute pulmonary edema. Within minutes of intubation, his airways became overflowed with copious amounts of serosanguinous fluid. The patient was given 10 mg IV of furosemide (Lasix) and IV fentanyl and midazolam for sedation. Positive-pressure ventilation was continued with the addition of approximately 5 cm cry Six hours after intubation, he was extubated. His ophthalmoplegia resolv completely the same day, and he had no permanent neurologic deficits. A chest x-ray film taken the following day showed marked improvement. He was discharged dwelling two days after the procedure

DISCUSSION

Neurogenic pulmonary edema occurr in our patient within minutes of a bupivacaine injection of the trigeminal cistern. Although other complications of trigeminal fortitude blockade have been reported, this complication has not been reported, to our knowledge.