After performing the block and starting a propofol infusion, the patient begins to flail about upon surgi-cal incision. Should you induce general anesthesia?
The first consideration in the agitated patient is hypoxia from respiratory compromise. In addition, hemodynamic instability, such as from a myocardial infarction, should be addressed as well. Another cause of agitation in this setting might be local anesthetic toxicity. Once these more serious causes are ruled out, one needs to consider the adequacy of the block(s) and other related causes. Patient movement from surgical incision does not necessarily mean that the block is inadequate. Some things to consider are:
· Was there enough time for the local anesthetic to take complete effect?
· Is the patient responding to pain or pressure?
· Is the propofol infusion causing burning in his arm?
· Is the patient disinhibited from the propofol infusion?
The skin is usually the last organ to be anesthetized and local infiltration by the surgeon will usually overcome this deficit. Of course any block, even in the best of hands, may fail and an alternative anesthetic will need to be instituted. Usually this means that general anesthesia is induced.