2023.1 Day 1 VIVA 4
A 65 year old female (60kg) is having a right total knee replacement.
Past medical history: Hypertension, Type 2 Diabetes, Glaucoma
Medications: Metoprolol, Candesartan, Metformin, eye drops
No known drug allergies.
You take over the case after your colleague has placed a spinal anaesthetic with 2.7ml 0.5% heavy bupivacaine and 15mcg fentanyl.
They have handed over the case, with an adequate block (motor block and T4 bilaterally to cold). Surgeons are prepping the skin.
The patient complains of nausea and starts dry retching. What do you do?
Assess vital signs immediately: Check BP, HR, SpO₂, ECG.
Common causes in spinal anaesthesia:
Hypotension (sympathetic blockade).
Bradycardia (Bezold-Jarisch reflex or high spinal).
High spinal block (respiratory involvement → urgent intervention).
You check vitals: BP 75/40 mmHg, HR 38 bpm. What is your diagnosis and management?
Diagnosis: High spinal with bradycardia & hypotension due to excessive sympathetic blockade.
Immediate management:
Ensure adequate oxygenation (high-flow O₂).
Position head-down (Trendelenburg) if tolerated to improve venous return.
Fluid bolus (500ml crystalloid) if no contraindications.
Vasopressors:
Ephedrine (5-10 mg IV) if both HR & BP are low.
Phenylephrine (50-100 mcg IV) if HR is normal but BP low.
Atropine (600 mcg IV) if persistent bradycardia.
Adrenaline (10-20 mcg IV boluses) if refractory hypotension or severe bradycardia.
How would you monitor and ensure the block is not rising further?
Check sensory level: Assess for spread beyond T4 (C8 hand paraesthesia suggests high block).
Assess motor block: Weak arms suggest very high spinal.
Monitor respiratory function:
If dyspnoea, hypoxia, or apnoea → prepare for intubatio
In PACU, the patient becomes agitated and lightheaded. What are your differential diagnoses?
Local Anaesthetic Systemic Toxicity (LAST) – large bupivacaine dose absorbed systemically. 📃(Notes)
Hypoxia/hypercapnia – respiratory depression.
Residual hypotension – ongoing spinal anaesthesia effects.
Hypoglycaemia – patient is diabetic on metformin.
Stroke or acute neuro event (less likely).
What are the clinical features of LAST? 📃(Notes)
Neurological signs (early): Agitation, dizziness, perioral tingling, metallic taste, seizures.
Cardiovascular signs (late): Hypotension, bradycardia, ventricular arrhythmias (VT, VF).
Severe cases: Cardiac arrest, refractory hypotension.
The patient develops persistent ventricular tachycardia (VT) but remains stable. How do you manage this?
First-line management:
Stop all local anaesthetic administration immediately.
20% intravenous lipid emulsion (ILE):
Bolus 1.5 ml/kg IV over 1 min (~90 mL for 60 kg patient).
Infusion at 0.25 ml/kg/min (increase to 0.5 ml/kg/min if needed).
Amiodarone a s first line anti-arrhythmic. Avoid local anaesthetic antiarrhythmics (e.g., lidocaine and class 1B anti-arrthmics due to exacerbation of Na channel block).
Supportive measures: IV fluids, vasopressors (noradrenaline if needed).
What if the patient deteriorates into cardiac arrest?
Continue ILE therapy.
ALS protocol, but adjust defibrillation doses if refractory. 📃(Notes)
Prolonged resuscitation often needed – do not give up early.
The patient has ongoing haemodynamic instability. What are your next steps?
Assess response to treatment: If unstable despite ILE, escalate care.
Prepare for transfer to a higher-level facility:
Contact retrieval team early.
Ensure airway protection (intubate if needed before transport).
Ongoing ILE infusion until transfer.
What key documentation is required after a critical incident?
Detailed clinical notes: Presentation, vital signs, treatments given.
Drug chart review: Verify doses of local anaesthetic.
Incident reporting: Notify anaesthetic department & quality assurance.
Debrief team & patient/family: Explain what happened and future precautions.
How would you communicate with the patient and family after this event?
Clear, factual, and empathetic explanation.
Reassure recovery is expected with no long-term effects.
Offer follow-up discussion and ensure they understand future risks.
Bonus Question
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