What is the recommended anesthetic plan for a left distal radius ORIF with a regional block, MAC, and a tourniquet?

Anesthetic Plan for Left Distal Radius ORIF with Regional Block, MAC, and Tourniquet

The optimal anesthetic plan for a left distal radius ORIF should include an ultrasound-guided brachial plexus block (preferably supraclavicular or infraclavicular approach), minimal sedation for MAC, and a forearm tourniquet rather than upper arm placement to minimize pain and sedation requirements.

Pre-procedure Assessment and Planning

• Evaluate patient's medical history focusing on:
  • Cardiovascular status (particularly for tourniquet tolerance)
  • Coagulation status (if considering regional anesthesia)
  • Previous anesthetic experiences and complications
  • Allergies to local anesthetics

Regional Block Selection

• Brachial plexus block is the primary regional technique for distal radius ORIF:
  • Supraclavicular or infraclavicular approaches are both effective and non-inferior to each other for distal radius ORIF 1
  • Use ultrasound guidance for accurate local anesthetic placement and reduced total dose 2
  • Long-acting local anesthetic (e.g., ropivacaine 0.5% or bupivacaine 0.5%) for extended post-operative analgesia

Block Procedure Ergonomics

• Position ultrasound machine directly in front of operator for optimal visualization 2
• Use in-plane needle approach along visual axis for improved accuracy and speed 2
• Dominant-hand needling is recommended, especially for novice practitioners 2
• Ensure proper hand positioning when holding the ultrasound probe (avoid "pinch" grip) 2

Monitored Anesthesia Care (MAC) Components

• Standard ASA monitoring (ECG, NIBP, SpO2, respiratory rate)
• Minimal sedation to maintain patient comfort while preserving consciousness:
  • Midazolam (1-2 mg IV) for anxiolysis
  • Small doses of fentanyl (25-50 mcg IV) or propofol (10-20 mg boluses) as needed for breakthrough discomfort
  • Avoid deep sedation to maintain patient's ability to communicate during the procedure

Tourniquet Management

• Use a forearm tourniquet rather than upper arm placement:
  • Results in significantly less pain and fewer sedation requirements 3, 4
  • Allows for lower doses of local anesthetic if using IVRA/Bier block as an alternative 4
  • Shorter tourniquet times (aim for <60 minutes) to minimize post-tourniquet syndrome
  • Consider immediate deflation after procedure completion rather than maintaining inflation for a set time 4

Multimodal Analgesia

• Pre-emptive analgesia:

  • Oral or IV NSAIDs (unless contraindicated) 2
  • IV acetaminophen 1g
  • Consider dexamethasone 4-8 mg IV for anti-inflammatory and anti-emetic effects

• Intraoperative:

  • Local wound infiltration with long-acting local anesthetic at surgical site as supplementary analgesia 2
  • Titrated opioids only if regional block is inadequate

Post-operative Pain Management

• Continue multimodal analgesia:

  • Scheduled NSAIDs and acetaminophen
  • Oral opioids only as rescue medication
  • Written instructions regarding when to take analgesics as the block wears off 2

• Provide patient with clear instructions about:

  • Expected duration of the regional block
  • How to protect the limb while sensation is diminished
  • When to start taking oral analgesics (before block wears off)
  • Signs of complications to watch for

Potential Complications and Management

• Block-related:

  • Vascular puncture: Apply pressure if occurs
  • Pneumothorax (with supraclavicular approach): Monitor for respiratory symptoms
  • Local anesthetic systemic toxicity: Have lipid emulsion readily available

• Tourniquet-related:

  • Tourniquet pain: Use forearm placement and minimize inflation time
  • Post-tourniquet syndrome: Early mobilization and appropriate analgesia

Alternative Approaches

If regional block is contraindicated or unsuccessful:

• Consider WALANT technique (Wide-Awake Local Anesthesia No Tourniquet) using local infiltration with lidocaine and epinephrine 5
• Intravenous regional anesthesia (Bier block) with forearm tourniquet is a safe and effective alternative 6, 4

This anesthetic plan prioritizes effective pain control, patient comfort, and rapid recovery while minimizing complications associated with both regional anesthesia and tourniquet use.