- The patient is a 52 year old white male
scheduled for excision of a large, painful
ganglion cyst of the left wrist. The surgeon has
requested sixty minutes of operative time.
- The preoperative anesthetic evaluation
was remarkable for being unremarkable. The
patient denied previous surgery and had no family
history of anesthetic complication. He has no
allergies, takes no medication, has never smoked
cigarettes and exercises regularly to maintain
his weight between 65 and 70 kg. The patient
preferred not to take medication and wondered if
this surgery can be done under a
"local". The anesthesiologist reviewed
the surgeons notes and found that the cyst was
thought to be quite extensively infiltrating the
subcutaneous tissue joint space.
- After considering the history, patient's
request and planned procedure, the
anesthesiologist recommended an intravenous
regional technique. The technique was explained
to the patient and informed consent was obtained.
- After positioning the patient supine on
the operating room table, the EKG, blood pressure
cuff and pulse oximeter were applied and readings
recorded. Heart rate 46 bpm, blood pressure
123/62 and pulse oximetry 98%. A 20 gauge IV of
lactated ringers was started in the right forearm
and a 22 gauge capped angiocath was placed in the
- The intravenous block was applied in the
usual fashion utilizing a double cuff tourniquet
on the left arm. The arm was exsanguinated of
blood with elevation and Esmarch wrap. Arterial
occlusion was confirmed before 50 cc of 0.5%
lidocaine was injected. "Pins and
Needles" sensation in the arm was noted
within seconds of the injection and full surgical
anesthesia was achieved within five minutes.
- Surgery commenced and within ten minutes
of incision, the thought-to-be-complexly
infiltrating ganglion was excised. The wound was
closed, dressing applied. Total tourniquet time
was 23 minutes.
- Within 30 seconds of the tourniquet
release, the patient asked why there was such a
bad taste in his mouth.
- He then demonstrated agitated
confusion and complained of roaring in his ears.
Within seconds his left arm began to twitch and
he was unresponsive.
- His breathing was irregular and
shallow, his heart rate was 100 bpm, pulse
oximetry showed 94%. The anesthesiologist
reinflated the tourniquet, applied an oxygen mask
and ventilating system and reached for the
- Before the
thiopental was administered, the twitching
stopped. The patient's breathing became more
regular. Within the next five minutes, the
patient opened his eyes and sluggishly asked,