Case Presentation Structure for Wide Humeral Resection Under Supraclavicular Block and General Anesthesia

I. Case Introduction (2-3 minutes)

Patient Demographics & Surgical Indication

Age, sex, BMI, relevant comorbidities (particularly respiratory function, OSA, cardiac risk factors) 1
Pathology requiring wide humeral resection (tumor type, location, extent)
Surgical approach and anticipated duration 2

Preoperative Assessment Highlights

Airway evaluation findings (Mallampati score, neck circumference, thyromental distance) 1, 2
Respiratory function (baseline oxygen saturation, any restrictive disease, FEV1 if available) 1, 2
Cardiovascular risk stratification (exercise tolerance, metabolic syndrome features) 2
Coagulation status and VTE risk 1

II. Anesthetic Planning & Block Selection Rationale (5-7 minutes)

Why Supraclavicular Block Was Chosen

The supraclavicular approach provides complete anesthesia of the entire upper extremity from mid-humerus distally with a single injection point, making it ideal for humeral shaft procedures. 3, 4

Anatomical Coverage Considerations

Supraclavicular block anesthetizes the entire brachial plexus at the "trunk" level, providing coverage of all terminal nerves (median, ulnar, radial, musculocutaneous) with high success rates 3, 4
For wide humeral resection, coverage must extend from shoulder (C5-C6) through mid-arm (C7-T1 distribution) 4, 5
If surgical incision extended proximally near shoulder joint, you should explicitly state whether supplemental interscalene or superficial cervical plexus block was considered 6, 5

Alternative Blocks Considered and Rejected

Interscalene block alone: Inadequate coverage of inferior trunk (C8-T1), leading to incomplete anesthesia of ulnar nerve distribution and medial arm 4
Infraclavicular block: While effective, requires more needle passes (though provides longer duration), and supraclavicular offers faster total anesthesia-related time 3
Axillary block: Significantly lower success rate (P<0.025 vs supraclavicular), poor nerve visibility, inadequate for proximal humeral surgery 3, 4

Combined Regional-General Anesthesia Approach

The combination of supraclavicular block with general anesthesia optimizes intraoperative conditions while providing superior postoperative analgesia and reduced opioid consumption. 1, 2

Intraoperative benefits: Reduced volatile anesthetic requirements, hemodynamic stability, decreased stress response 1, 2
Postoperative benefits: Extended analgesia (8-16 hours typical duration), reduced opioid consumption by approximately 30-40%, earlier mobilization 1, 3
General anesthesia rationale: Prolonged surgical duration, patient preference for unconsciousness, airway protection during positioning 1, 2

III. Block Technique & Execution (3-4 minutes)

Ultrasound-Guided Approach Details

All brachial plexus blocks should be performed with ultrasound guidance to reduce local anesthetic systemic toxicity risk and improve success rates. 7, 3

Technical Specifications You Should Present

Patient positioning: Supine with head turned 30-45° away, arm at side 3
Probe placement: Linear high-frequency probe in supraclavicular fossa, just lateral to subclavian artery 3, 4
Sonoanatomy identified: Brachial plexus appearing as "cluster of grapes" lateral and superficial to subclavian artery, first rib as hyperechoic landmark 3
Needle approach: In-plane lateral-to-medial or out-of-plane technique (specify which you used) 3

Injection Strategy

Local anesthetic choice and volume: Ropivacaine 0.5-0.75% or bupivacaine 0.5%, total volume 20-30mL 3, 4
Multiinjection intracluster technique: 2-3 injections within the plexus cluster to ensure circumferential spread (reduces performance time and improves success) 3
Nerve stimulation parameters if used: Threshold 0.5-0.9 mA to confirm proximity without intraneural injection 4

Adjuvants Administered

Dexamethasone 4-8mg perineural or IV: Prolongs block duration by 4-6 hours, provides antiemetic effect 1, 2
Avoid epinephrine in this location due to proximity to vertebral artery 4

Block Assessment

Sensory testing: Cold sensation or pinprick in all five nerve distributions (median, ulnar, radial, musculocutaneous, medial cutaneous nerve of arm) 3
Motor testing: Inability to flex elbow (musculocutaneous), extend wrist (radial), oppose thumb (median) 3
Time to surgical anesthesia: Typically 15-25 minutes for supraclavicular block 3
Success definition: Complete sensory and motor block in surgical field without need for supplementation 3

IV. Multimodal Analgesia & Perioperative Management (3-4 minutes)

Systemic Analgesic Regimen

Multimodal analgesia combining paracetamol, NSAIDs, and dexamethasone should be administered pre/intraoperatively to optimize postoperative pain control when block resolves. 1, 2

Paracetamol 1g IV administered intraoperatively, continued 1g PO q6h postoperatively 1, 2
COX-2 inhibitor or NSAID (celecoxib 200mg PO or ketorolac 30mg IV) unless contraindicated by renal function or bleeding risk 1, 2
Dexamethasone 8-10mg IV for analgesic prolongation and PONV prophylaxis 1, 2
Opioids reserved as rescue analgesia only, with multimodal approach reducing consumption by 40-60% 1, 2

General Anesthesia Technique

Use short-acting agents allowing rapid emergence to facilitate early neurological assessment and mobilization. 1, 2

Induction: Propofol 1.5-2.5mg/kg, fentanyl 1-2mcg/kg (reduced due to regional block) 1, 2
Maintenance: Sevoflurane or desflurane in oxygen-enriched air, or TIVA with propofol/remifentanil 1, 2
Neuromuscular blockade: Rocuronium with neuromuscular monitoring, deep block facilitates surgical exposure 1
Avoid excessive depth: BIS monitoring 40-60 to prevent postoperative cognitive dysfunction, particularly in elderly 1

Intraoperative Hemodynamic Management

Maintain systolic blood pressure within 20% of baseline using vasopressors rather than excessive fluid administration. 2

Goal-directed fluid therapy: Restrict crystalloid to <500mL/hour, use vasopressors (phenylephrine, norepinephrine) for blood pressure support 1, 2
Avoid fluid overload: Excessive salt and water increases complications and delays recovery 1
Normothermia maintenance: Forced-air warming device, warmed IV fluids, target core temperature >36°C 2

PONV Prophylaxis

Multimodal PONV prophylaxis is mandatory for major upper extremity surgery, which carries 50-70% baseline risk. 1

Dexamethasone 8mg IV (already given for analgesia) 1, 2
5-HT3 antagonist (ondansetron 4mg IV at end of case) 1
Consider adding droperidol 0.625mg or scopolamine patch if high-risk patient 1
Avoid volatile anesthetics and nitrous oxide if PONV history present (use TIVA instead) 1

V. Postoperative Care & Monitoring (2-3 minutes)

Recovery Phase Management

Patients with functioning supraclavicular blocks can bypass first-stage recovery and proceed directly to second-stage recovery area. 1

Fast-tracking criteria: Awake, hemodynamically stable, no respiratory compromise, pain controlled by block 1
Monitoring requirements: Standard vital signs, neurovascular checks of blocked extremity q1h until block resolution 1, 8
Mobilization: Arm in sling, avoid weight-bearing on affected extremity until motor function returns 1

Critical Complication Surveillance

The most critical postoperative concern is acute compartment syndrome, which can present with disproportionate pain despite dense sensory block. 8

Warning Signs to Monitor

Out-of-proportion pain with odd distribution despite established block (hallmark sign) 8
Progressive limb swelling and tense compartments on palpation 8
Loss of distal pulses (late finding, indicates advanced compartment syndrome) 8
Pain with passive stretch of muscles in affected compartment 8

Management Protocol

High index of suspicion: Any concerning pain pattern requires immediate surgical evaluation 8
Do not attribute pain to "block wearing off" if timing inconsistent or distribution atypical 8
Urgent surgical consultation for compartment pressure measurement and potential fasciotomy 8
Document neurovascular status meticulously every hour until block fully resolved 8

Discharge Planning

Patients require written and verbal instructions about block resolution timeline and when to resume analgesics. 1

Expected block duration: 8-16 hours for sensory block, 6-12 hours for motor block 3
Analgesic transition plan: Begin oral multimodal regimen 2-3 hours before expected block resolution 1
Arm protection instructions: Sling use, avoid heat/cold exposure to insensate limb, no driving until motor function returns 1
Red flag symptoms: Severe pain, numbness persisting >24 hours, weakness persisting >48 hours warrant immediate contact 1

VI. Complications & Risk Mitigation (2-3 minutes)

Block-Specific Complications Discussed During Consent

Patients must understand significant foreseeable risks including pneumothorax, vascular puncture, nerve injury, and local anesthetic systemic toxicity. 1

Supraclavicular Block-Specific Risks

Pneumothorax: 0.5-6% incidence (higher with landmark technique, <0.5% with ultrasound) 4
Phrenic nerve palsy: 50-67% incidence (usually asymptomatic, but problematic in severe respiratory disease) 4
Horner's syndrome: 10-20% incidence (temporary, resolves with block) 4
Vascular puncture: Subclavian artery proximity requires careful needle visualization 3, 4

General Anesthetic Risks

Nerve/eye damage, awareness, death (serious but rare complications requiring disclosure) 1
Common side effects: Nausea/vomiting (30-50%), sore throat (40-60%), dental trauma (<0.1%) 1

How Risks Were Minimized in Your Case

Ultrasound guidance: Real-time visualization of needle, pleura, and vascular structures 7, 3
Aspiration before injection: Every 3-5mL to detect intravascular placement 4
Incremental injection: Allows early detection of systemic toxicity symptoms 7
Lipid emulsion availability: 20% intralipid immediately available in block area 7

VII. Outcome & Learning Points (1-2 minutes)

Case Outcome

Block success: Complete surgical anesthesia achieved, no supplemental local anesthetic required
Intraoperative course: Hemodynamically stable, reduced volatile anesthetic requirements
Postoperative analgesia: Pain scores <3/10 for first 12 hours, minimal opioid consumption
Complications: None (or describe any that occurred and management)
Hospital course: Discharge timing, functional recovery

Key Teaching Points for Your Presentation

Emphasize these evidence-based principles:

Supraclavicular block provides optimal coverage for mid-humeral surgery with single-injection simplicity and high success rates 3, 4
Ultrasound guidance is mandatory for safety and efficacy in modern regional anesthesia practice 7, 3
Multimodal analgesia extends pain control beyond block duration and reduces opioid-related complications 1, 2
Vigilant postoperative monitoring is essential to detect compartment syndrome, which can present atypically with regional anesthesia 8
Combined regional-general technique optimizes both intraoperative conditions and postoperative recovery 1, 2

Relevant Literature to Reference

High-Impact Studies for Your Discussion

Tran et al. (2016): Comparative trial of supraclavicular vs infraclavicular vs axillary blocks with 20mL volume, demonstrating supraclavicular superiority in success rate and total anesthesia time 3
PROSPECT guidelines for shoulder surgery (2019): Establishes interscalene/suprascapular blocks as gold standard, but principles apply to proximal arm surgery 1
Neal et al. (2015): Case report highlighting compartment syndrome presentation with established brachial plexus block, emphasizing "out-of-proportion pain" as key diagnostic feature 8

Guidelines to Frame Your Approach

AAGBI consent guidelines (2017): Framework for discussing risks and alternatives with patients 1
ASRA/ESRA ultrasound guidance recommendations: Technical standards for peripheral nerve blocks 7
Enhanced recovery protocols: Multimodal analgesia and opioid-sparing strategies 1, 2

How should I present a case of a patient who underwent wide resection of the humerus under supraclavicular brachial plexus block and general anesthesia for a case presentation in regional anesthesia fellowship?

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