Patient safety incident review: a rare occurrence of central anesthesia from a local anesthetic block during an ophthalmology procedure

The following information and recommendations are being shared to assist facilities in their continuous quality improvement.

The Non-Hospital Medical and Surgical Facilities Accreditation Program Patient Safety Incident Review Panel recently reviewed an incident involving a patient that received a retrobulbar block with local anesthesia for an ophthalmology procedure. 

The anesthesiologist noted the patient’s blood pressure increasing following sedation but with decreased responsiveness as well as irregular respiratory rate on qualitative CO2 monitoring. The two most likely diagnoses were recognized immediately (CVA, central anesthesia) and as the clinical team was unable to bag-valve mask, the patient was intubated and transferred to hospital. The CT scan and CT angiogram did not show evidence of stroke and it was the opinion of the neurologist that this was a case of brainstem anesthesia secondary to retrobulbar block.

Contributing factors to this incident included:

  • no contributory patient factors were noted, and
  • the performance of a second block following a failed initial block.

In reviewing this patient safety incident, the panel indicated that the rare complication was managed well. The patient made a complete recovery once the effects of the anesthesia wore off. The panel recommended that the facility discuss this case with the clinical team at quality improvement rounds (morbidity and mortality rounds) to share learning. 

It was also recommended that this incident be shared more widely to remind facilities of the possibility of rare complications, and that discussions be held with clinical teams to ensure recognition of this complication and that the emergency response is reviewed.