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?

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

Recommended Presentation Format

Your case presentation should follow a structured clinical format that emphasizes the decision-making process for regional anesthesia selection, not SBAR, which is designed for handoffs rather than educational presentations. 1

I. Case Introduction (2-3 minutes)

• Patient demographics: Age, sex, BMI, and relevant comorbidities (particularly respiratory function, OSA, cardiac risk factors) 1
• Surgical indication: Pathology requiring wide humeral resection (tumor, infection, trauma)
• Anesthetic plan: Combined supraclavicular brachial plexus block with general anesthesia

II. Preoperative Assessment (3-4 minutes)

Airway Evaluation

• Mallampati score, neck circumference, thyromental distance 1
• Document any predictors of difficult airway management

Respiratory Function

• Baseline oxygen saturation, any restrictive disease 1
• This is critical because supraclavicular blocks carry higher risk of phrenic nerve involvement compared to infraclavicular approaches 2

Cardiovascular Risk

• Exercise tolerance, metabolic syndrome features 1
• Hemodynamic stability considerations for combined technique

III. Block Selection Rationale (5-7 minutes)

Why Supraclavicular Over Other Approaches

• For humeral surgery, supraclavicular block provides the most complete coverage of the surgical field with highest success rates 3
• Supraclavicular approach demonstrated significantly higher success rate versus axillary approach and reduced total anesthesia-related time versus infraclavicular approach 3
• The multiinjection intracluster technique at the supraclavicular level exhibited no early adverse events in comparative studies 3

Caveat: Acknowledge that infraclavicular blocks are preferred when respiratory function preservation is the priority, as supraclavicular approaches are more likely to interfere with respiratory mechanics 2. However, for wide humeral resection requiring extensive surgical exposure, the supraclavicular approach provides superior anatomical coverage 3, 4

Why Combined with General Anesthesia

• The combination optimizes intraoperative conditions while providing superior postoperative analgesia and reduced opioid consumption 1
• Intraoperative benefits: reduced volatile anesthetic requirements, hemodynamic stability, decreased stress response 1
• Postoperative benefits: extended analgesia, reduced opioid consumption, earlier mobilization 1

IV. Technical Execution (4-5 minutes)

Block Procedure

• Ultrasound guidance is mandatory for safety and efficacy in modern regional anesthesia practice 1, 2
• Describe your needle approach, local anesthetic choice and volume
• Document nerve stimulation parameters if used (minimal threshold 0.9 mA for supraclavicular blocks) 4
• Multiinjection technique details 3

General Anesthesia Management

• Standard induction technique allowing rapid awakening 1
• Reduced volatile anesthetic requirements due to functioning block 1
• Hemodynamic management maintaining systolic blood pressure within 20% of baseline 5

V. Multimodal Analgesia Protocol (2-3 minutes)

Pre/Intraoperative Administration

• Paracetamol 1g IV intraoperatively 1
• COX-2 inhibitor or NSAID (celecoxib 200mg PO or ketorolac 30mg IV) unless contraindicated by renal function or bleeding risk 1
• Dexamethasone 8-10mg IV for analgesic and antiemetic effects 1, 5

Postoperative Continuation

• Paracetamol 1g PO q6h 1
• Continue NSAID/COX-2 inhibitor as appropriate 1

VI. Postoperative Management (2-3 minutes)

Fast-Tracking Criteria

• Patients with functioning supraclavicular blocks can bypass first-stage recovery and proceed directly to second-stage recovery 1
• Criteria: awake, hemodynamically stable, no respiratory compromise, pain controlled by block 1

Monitoring Requirements

• Standard vital signs 1
• Neurovascular checks of blocked extremity q1h until block resolution 1
• Critical pitfall: Vigilant monitoring for compartment syndrome, which can present atypically with regional anesthesia 1, 6

VII. Complications and Risk Mitigation (3-4 minutes)

Informed Consent Discussion

• Pneumothorax (particularly relevant for supraclavicular approach) 1
• Vascular puncture 1
• Nerve injury 1
• Local anesthetic systemic toxicity 1, 2

Critical Case Report to Discuss

• Present the Romanian case of acute compartment syndrome after supraclavicular block for radius fracture 6
• The hallmark was out-of-proportion pain with odd distribution despite dense sensory and motor block 6
• Emphasize that pain breakthrough in the presence of functioning block should trigger immediate surgical evaluation 6

VIII. Outcome and Lessons Learned (2-3 minutes)

• Actual block performance time and success
• Intraoperative opioid requirements
• Postoperative pain scores and opioid consumption
• Time to discharge
• Any complications or deviations from plan
• What you would do differently

Key Pitfalls to Address

Do not ignore respiratory considerations: While you chose supraclavicular for anatomical coverage, acknowledge that patients with significant respiratory compromise might benefit from infraclavicular approach despite potentially longer performance time 2, 3

Compartment syndrome vigilance: This is the most dangerous complication that can be masked by regional anesthesia—emphasize your monitoring protocol 1, 6

Block failure contingency: Have a clear plan for supplementation or conversion to general anesthesia alone if block inadequate 3