A 60-year-old woman, weighing 48 kg, height 156 cm and ASA III.
He smoked 20 cigarettes a day, with a history of total post-traumatic blindness and difficulty walking without support that had not been studied.
He was admitted to the vascular surgery service of our center due to chronic ischemia of the right lower limb grade IV, pending surgical treatment by supracondylar amputation of that limb.
The preoperative study showed normal microcytic hypochromic anemia, coagulation and biochemistry, and an electrocardiogram repolarization disorder.
During his stay in the service he continued pain of the right lower limb, continuously and progressively intolerable, requiring placement of an epidural catheter at L3-L4 level for the connection of a bolus of 0.2 ml ropivacaine plus a bolus infusion pump (PCP).
The puncture was performed with an 18 G Tuohy needle. The placement of the catheter was technically simple and without incidents.
There was no aspiration of blood or cerebrospinal fluid and the test dose (4 ml of 0.25 % bupivacaine with vasoconstrictor) was negative.
The patient had not received anticoagulant treatment within 12 hours prior to catheter placement.
After the first 24 hours after placement of the epidural catheter, the patient presented worsening of premedication symptoms: more severe pain in the right lower limb, associated with complete motor blockade of both lower limbs.
The perfusion was suspended through the epidural catheter and the patient was reevaluated after 2, 4 and 8 hours.
The examination 8 hours later showed a monoplegia of the right lower limb and a monoparesis of the left lower limb without incontinence of the anal sphincter (the patient had a urinary catheter).
At all times, our patient presented lumbar pain.
We proceeded to the removal of the epidural catheter requiring an imaging study with MRI of the lumbar spine in which vertebral fractures L1, L2 and L4 were evidenced, as well as a marked dyscal stenosis L3-L4 lumbar canal aggravated
1.
Treatment with dexamethasone 4 mg/6 h was initiated and the patient was transferred to the neurosurgery department for evaluation.
During his admission to the neurosurgery service, electromyography was performed, showing an involvement of the peripheral nervous system that could correspond to a mixed polyneuropathy.
With all these data, it was considered that the patient's clinic was the result of a combination of multiple pathologies, and surgical intervention was discouraged because it would not benefit from this treatment.
Finally, the patient was referred to the vascular surgery service to complete the surgical treatment.
Supracondylar amputation of the right lower limb was performed under general anesthesia with i-gelTM laryngeal mask (Intersurgical Ltd.,Wokingham, England) number 4.
Anesthesia was induced by intravenous administration of fentanyl 2 μg/kg and propofol 2 mg/kg. The maintenance of anesthesia was performed with 2 % sevofluorane in a fresh oxygen-air mixture with 1 % blood pressure.
Standard monitoring of the patient was performed and hemodynamic stability was established throughout surgery.
At the end of the procedure, the laryngeal mask airway was removed when the patient was completely removed.
She was admitted to the postanesthetic recovery unit where she remained for 2 hours.
His evolution was favorable.
