Author: J. Nmezi
Cureus, June 23, 2026
Acute anxiety can occur during awake regional anesthesia, but a true intraoperative panic attack is uncommon and may be mistaken for a high spinal block, local anesthetic toxicity, pulmonary embolism, anaphylaxis, or another medical emergency.
This case report describes a 52-year-old woman with no previous psychiatric history who developed a severe panic attack during total knee replacement under spinal anesthesia. Brief psychological intervention resolved her symptoms within eight minutes and allowed the operation to continue without sedation or conversion to general anesthesia.
Case presentation
The patient underwent spinal anesthesia at L3-L4 using:
• 2.5 mL of 0.5% hyperbaric bupivacaine
• Fentanyl 25 µg
A T10 sensory level was initially obtained, and surgery began with stable vital signs.
Approximately 35 minutes later, she suddenly developed:
• Severe anxiety and agitation
• Chest tightness
• Palpitations
• Dyspnea and rapid shallow breathing
• Uncontrollable trembling
• Diaphoresis
• A sense of impending death
Her heart rate increased to 142 beats per minute, blood pressure rose to 180/95 mmHg, and respiratory rate increased to 28 breaths per minute. Oxygen saturation remained 98% on room air, and electrocardiography showed sinus tachycardia without ectopy.
Differential diagnosis
The anesthesia team considered several potentially serious causes.
High spinal anesthesia was considered unlikely because the sensory level was only T8, blood pressure was elevated rather than reduced, and upper-extremity strength was preserved.
Local anesthetic systemic toxicity was unlikely because there were no neurologic prodromes, seizures, arrhythmias, or cardiovascular collapse.
Anaphylaxis was unlikely because there was no rash, bronchospasm, or hypotension.
Pulmonary embolism was considered less likely because oxygen saturation remained normal and the clinical presentation lacked supporting findings.
Hemorrhage was excluded because the surgical field was dry.
The combination of abrupt intense fear, hyperventilation, tachycardia, hypertension, trembling, chest tightness, and a feeling of impending death was judged most consistent with an acute panic attack.
Psychological intervention
The attending anesthetist used four brief psychological techniques.
Grounding
The clinician calmly told the patient that she was safe and that the symptoms represented a panic attack that would pass.
She was asked to identify objects in the operating room, and a cool cloth was placed on her forehead to redirect attention away from internal sensations.
Breathing retraining
The patient was coached to inhale for four seconds, hold for four seconds, and exhale for four seconds.
The clinician breathed with her until the respiratory rate decreased from 28 to 16 breaths per minute.
Cognitive reassurance
The clinician explained that the palpitations, trembling, and chest discomfort were caused by an adrenaline surge rather than a life-threatening event.
The patient was reassured that surgery would continue only when she felt ready.
Guided imagery
She was asked to imagine her garden and describe its sights, sounds, and smells.
Outcome
Within eight minutes:
• Heart rate decreased from 142 to 98 beats per minute.
• Blood pressure improved from 180/95 to 148/84 mmHg.
• Trembling stopped.
• The patient reported feeling calm enough to continue.
The remaining surgery was completed uneventfully, and no intravenous sedation was required.
She remained stable in recovery and was discharged on postoperative day three. At four weeks and six months, she reported no recurrent panic attacks and remained satisfied with her surgical outcome.
Clinical implications
An acute panic attack should be considered when a patient undergoing regional anesthesia develops sudden severe fear, tachycardia, hypertension, hyperventilation, trembling, and a sense of impending death without evidence of hypoxia, hypotension, ascending block, arrhythmia, or allergic reaction.
Psychological first aid may prevent unnecessary sedation, interruption of surgery, or conversion to general anesthesia.
Useful bedside techniques include:
• Speaking calmly and naming the likely problem
• Reassuring the patient that the symptoms are temporary
• Slowing and regulating breathing
• Directing attention toward external objects
• Explaining that physical symptoms are caused by adrenaline
• Using guided imagery or another familiar calming mental focus
Sedation or general anesthesia may still be necessary if agitation threatens patient safety, the intervention fails, or an organic cause cannot be excluded.
However, conversion to general anesthesia should not be automatic when a stable patient develops psychological distress during regional anesthesia.
Important limitations
This report describes only one patient, so the outcome cannot be generalized to all patients experiencing intraoperative anxiety.
The intervention was delivered by an anesthetist with clinical psychology training, and the same degree of success may not be achieved by every clinician.
The diagnosis of panic should only be made after urgent physiological causes have been assessed and excluded.
The report does not establish how frequently intraoperative panic attacks occur or whether psychological intervention is superior to pharmacologic sedation.
Bottom line
Acute panic attacks can occur during spinal anesthesia even in patients without a history of anxiety or psychiatric illness.
When serious medical causes have been excluded, grounding, breathing retraining, cognitive reassurance, and guided imagery may rapidly control symptoms and allow surgery to continue without sedation or conversion to general anesthesia.
Basic psychological first-aid techniques may be a valuable addition to anesthesia training and intraoperative crisis management.
Thank you to Cureus for allowing us to summarize this case report.