title: Difficult intubation and brain-stem anaesthesia.
abstract: OBJECTIVE
  To present a case of difficult intubation with brainstem anaesthesia after retrobulbar block with bupivacaine and lidocaine and sedation with midazolam and to point out that close monitoring and timely treatment is important in preventing an unfavourable outcome.
  
  
  METHODS
  An 82-yr-old man with treated hypertension and stable angina was scheduled for cataract extraction. Physical examination revealed a class 2 airway. He had a retrobulbar block after topical tetracaine drops, with bupivacaine 0.5% and lidocaine 2% with hyaluronidase under sedation with 1 mg midazolam. Five minutes after the block, respiration slowed, he became unresponsive and oxygen saturation decreased to 80%. Immediate ventilation with mask without additional oxygen improved saturation. Attempted tracheal intubation failed: the epiglottis could not be visualized despite flaccid jaw and extremities. A laryngeal mask airway was placed which was leaking and adequate ventilation could not be achieved but a second laryngeal mask airway was placed successfully.
  
  
  CONCLUSIONS
  This case emphasizes the need for dose monitoring and personnel capable of managing the difficult airway when intra-orbital anaesthesia is used.
authors.affiliation: Department of Anaesthesia, Mount Sinai Hospital, University of Toronto, Ontario.
authors.forename: C
authors.initials: C
authors.lastname: Ananthanarayan
authors.forename: A F
authors.initials: AF
authors.lastname: Cole
authors.forename: M
authors.initials: M
authors.lastname: Kazdan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001933:Brain Stem / Q000187:drug effects*; D002387:Cataract Extraction; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D009407:Nerve Block / Q000009:adverse effects*