Anesthetic Technique Selection for High-Grade Spindle Cell Sarcoma Resection

Recommended Anesthetic Approach

For this 56-year-old female undergoing wide resection and burring of right humerus for high-grade spindle cell sarcoma, the optimal anesthetic technique is combined supraclavicular brachial plexus block with general endotracheal anesthesia (GETT), utilizing multimodal analgesia and opioid-sparing techniques to minimize cardiopulmonary complications in this patient with atrial fibrillation, eccentric LV hypertrophy, and mild mitral regurgitation. 1, 2

Case Presentation Structure

Patient Demographics and Diagnosis

56-year-old female, 70 kg, BMI 26.7 (overweight but not obese) 1
Diagnosis: High-grade spindle cell sarcoma of right humerus, Enneking Stage III, ACC Stage IV 3, 4
Planned Procedure: Wide resection and burring of right humerus (prolonged orthopedic oncologic surgery requiring optimal surgical exposure and postoperative pain control) 2

Relevant Medical History

Respiratory System:

Remote history of bronchial asthma (last attack 20 years ago - currently not active) 1
Clinical Significance: Minimal current respiratory risk, but requires avoidance of histamine-releasing agents and consideration of bronchodilator availability 1

Cardiovascular System:

Atrial fibrillation with controlled ventricular response - requires rate control maintenance and anticoagulation consideration 1
Eccentric LV hypertrophy with EF 60% - indicates diastolic dysfunction with preserved systolic function 1
Mild mitral regurgitation - may worsen with tachycardia or increased afterload 1
Clinical Significance: Patient is at increased risk for hemodynamic instability with rapid anesthetic induction and requires careful titration of anesthetic agents 5

Metabolic/Endocrine:

Type 2 diabetes mellitus - requires perioperative glucose monitoring and management 1
Dyslipidemia - suggests underlying atherosclerotic disease risk 1

Oncologic Considerations:

High-grade spindle cell sarcoma is extremely aggressive with poor prognosis (mean survival 3 months to 1 year, 5-year survival 8%) 3, 4, 6, 7
Propensity for rapid metastasis and recurrence even after surgical resection 4, 7
Clinical Significance: Aggressive surgical approach warranted; anesthetic plan must facilitate optimal surgical conditions while minimizing morbidity 3, 6

Decision-Making Algorithm for Anesthetic Technique Selection

Step 1: Assess Surgical Requirements

Surgical Factors Favoring General Anesthesia:

Prolonged procedure duration (wide resection + burring requires 3-4+ hours) 2
Surgical positioning requirements (likely lateral decubitus or supine with arm abduction) 2
Need for optimal surgical exposure and immobility during oncologic resection with bone work 2
Potential for significant blood loss during wide resection 2

Conclusion: General endotracheal anesthesia is mandatory for this procedure 2, 8

Step 2: Evaluate Patient-Specific Factors

Cardiovascular Risk Assessment:

AF with controlled ventricular response + eccentric LVH + mild MR = ASA-PS III patient 1
Risk: Hemodynamic instability with rapid induction, intolerance of hypotension, and increased myocardial oxygen demand 1, 5
Mitigation Strategy: Slow, titrated induction with propofol 1.5-2.0 mg/kg (reduced from standard 2-2.5 mg/kg) combined with fentanyl 1.5-2.0 mcg/kg 2, 5

Respiratory Considerations:

BMI 26.7 (overweight, not obese) - minimal increased airway risk 1, 9
Remote asthma history - not currently active, low risk 1
Airway Management: Standard endotracheal intubation with tube size based on ideal body weight (likely 7.0-7.5mm for female) 9

Pain Management Requirements:

Extensive bone and soft tissue dissection will produce severe postoperative pain 2
Cardiovascular comorbidities make high-dose systemic opioids undesirable (risk of respiratory depression, hypotension) 1, 2
Regional anesthesia is strongly indicated to provide opioid-sparing analgesia 1, 2

Step 3: Regional Anesthesia Selection

Why Supraclavicular Brachial Plexus Block is Optimal:

Provides complete anesthesia of upper extremity from mid-humerus distally - ideal for humeral resection 1
Enables significant opioid reduction (50-70% reduction in intraoperative and postoperative opioid requirements) 1, 2
Reduces cardiovascular stress by minimizing opioid-related hemodynamic effects 1, 2
Facilitates early mobilization without epidural-related motor blockade 1
Provides 12-18 hours of postoperative analgesia when performed with long-acting local anesthetic 1

Technical Considerations:

Ultrasound-guided technique recommended for higher success rate in overweight patients 1
Local anesthetic dosing: Calculate based on lean body weight (approximately 60 kg for this patient) 1
Recommended agents: 0.5% ropivacaine 20-30 mL or 0.5% bupivacaine 20-30 mL for prolonged duration 1

Alternative Regional Options Considered and Rejected:

Interscalene Block:

Rejected because it provides inadequate coverage of lower humerus (C8-T1 distribution often missed) 1
Risk of phrenic nerve palsy problematic in patient with cardiac disease 1

Axillary Block:

Rejected because surgical site (proximal humerus) is above the level of reliable axillary block coverage 1

Thoracic Epidural (T2-T4):

Rejected because it provides less reliable upper extremity anesthesia compared to brachial plexus block 2
Increased risk of hypotension problematic in patient with AF and LVH 1
Impairs postoperative mobilization 1

Step 4: General Anesthesia Technique

Induction:

Propofol 1.5-2.0 mg/kg IV (reduced dose for age >55 and cardiac disease) administered slowly over 60-90 seconds 2, 5
Fentanyl 1.5-2.0 mcg/kg IV for analgesia during laryngoscopy 2
Rocuronium 0.6-1.0 mg/kg IV for neuromuscular blockade (reversible with sugammadex if airway difficulty) 2
Avoid rapid bolus administration to prevent hypotension, apnea, and cardiovascular depression in this ASA-PS III patient 5

Airway Management:

Endotracheal intubation with cuffed tube (7.0-7.5mm based on ideal body weight) 2, 8, 9
Ramped positioning if any difficulty anticipated (tragus level with sternum) 9
Continuous waveform capnography to confirm and monitor ETT placement 9

Maintenance:

Volatile anesthetic (sevoflurane or desflurane) OR propofol TIVA 100-150 mcg/kg/min 1, 2, 5
Lung-protective ventilation: Tidal volume 6-8 mL/kg ideal body weight, PEEP 6-8 cmH2O 2
Neuromuscular monitoring throughout to maintain surgical relaxation and ensure complete reversal before extubation 1, 2

Multimodal Analgesia:

Acetaminophen 1000mg IV at induction 2
Ketorolac 15-30mg IV (if no contraindication with anticoagulation for AF) 2
Minimize intraoperative opioids due to effective regional block 1, 2

Monitoring:

Standard ASA monitoring: ECG (continuous for AF monitoring), pulse oximetry, non-invasive blood pressure every 3-5 minutes, capnography, temperature, neuromuscular monitoring 2
Consider arterial line if significant blood loss anticipated or for beat-to-beat BP monitoring in patient with cardiac disease 1

Step 5: Emergence and Extubation

Reversal:

Sugammadex 2-4 mg/kg for rocuronium reversal, ensuring train-of-four ratio ≥0.90 before extubation 2
Awake extubation in semi-sitting position (30-45 degrees head-up) 1, 8
Maintain head-up position throughout recovery to optimize respiratory mechanics 1

Extubation Criteria:

Return of airway reflexes 1
Adequate tidal volumes and respiratory rate 1
Oxygen saturation at baseline without supplementation 1
Patient awake and following commands 1, 8

Postoperative Care Plan

Analgesia:

Supraclavicular block provides 12-18 hours of analgesia 1
Multimodal oral analgesia: Acetaminophen 1000mg q6h + NSAID (if appropriate) 1, 2
Oral opioids PRN for breakthrough pain (minimize use due to cardiac/respiratory risk) 1
Avoid PCA in this patient with cardiac disease unless in monitored setting 1

Monitoring:

Continuous pulse oximetry until mobile and off supplemental oxygen 1
Cardiac monitoring for AF rate control 1
Blood glucose monitoring for diabetes management 1

Mobilization:

Early mobilization on day of surgery (within 6-8 hours) to reduce VTE risk and improve outcomes 1
Sequential compression devices for VTE prophylaxis 2
Resume anticoagulation for AF per timing guidelines (consider surgical bleeding risk) 2

Level of Care:

Ward-level care appropriate if hemodynamically stable, adequate pain control, and no respiratory compromise 1
Consider step-down unit if ongoing hemodynamic monitoring needed for AF or if requiring supplemental oxygen 1

Alternative Anesthetic Options (Not Recommended for This Case)

Regional Anesthesia Alone:

Not feasible - supraclavicular block alone cannot provide the immobility, airway control, and hemodynamic management required for prolonged oncologic bone surgery 1, 2

General Anesthesia Without Regional Block:

Suboptimal - would require high-dose opioids (increased risk of respiratory depression, hypotension, PONV, delayed mobilization) in patient with cardiac disease 1, 2
Inferior pain control postoperatively, limiting early mobilization 1

Neuraxial Anesthesia (Spinal/Epidural):

Not applicable - cannot provide anesthesia for upper extremity surgery 1, 2

Critical Pitfalls to Avoid

Induction Hazards:

Never use rapid bolus propofol in this ASA-PS III patient with cardiac disease - causes severe hypotension, apnea, and cardiovascular collapse 5
Avoid using actual body weight for drug dosing - use ideal body weight for propofol and lean body weight for local anesthetics 1, 9, 5

Regional Block Errors:

Do not perform block without ultrasound guidance in overweight patient - increases failure rate 1
Do not exceed maximum local anesthetic dose calculated on lean body weight 1
Ensure adequate time (20-30 minutes) for block onset before surgical incision 1

Cardiovascular Management:

Avoid tachycardia - worsens mitral regurgitation and increases myocardial oxygen demand in patient with LVH 1, 5
Avoid significant hypotension - compromises coronary perfusion in patient with likely diastolic dysfunction 1, 5
Maintain euvolemia - patient with LVH poorly tolerates both hypovolemia and fluid overload 1

Extubation Risks:

Never extubate deep in patient with cardiac disease and overweight BMI - high risk of airway obstruction and hypoxemia 1, 8
Ensure complete neuromuscular reversal before extubation to prevent postoperative respiratory complications 1, 2

Postoperative Complications:

Do not discharge to ward if requiring supplemental oxygen or having episodes of desaturation - requires extended PACU monitoring or step-down unit 1
Monitor for block-related complications (Horner's syndrome, phrenic nerve palsy, pneumothorax) in first 24 hours 1

Summary Algorithm

SURGICAL REQUIREMENTS → Prolonged duration + Positioning + Immobility
                     ↓
              GETT MANDATORY

PATIENT FACTORS → ASA-PS III (AF, LVH, MR) + Overweight + DM
                ↓
         SLOW TITRATED INDUCTION
         (Reduced propofol dose)

PAIN REQUIREMENTS → Extensive bone/soft tissue surgery
                  ↓
            OPIOID-SPARING NEEDED
            (Cardiac disease)
                  ↓
         REGIONAL ANESTHESIA INDICATED

REGIONAL OPTIONS → Interscalene (inadequate coverage)
                → Axillary (too distal)
                → Epidural (less reliable, impairs mobilization)
                ↓
         SUPRACLAVICULAR BLOCK OPTIMAL
         (Complete humeral coverage + opioid-sparing)

FINAL TECHNIQUE → Supraclavicular Block + GETT
                → Multimodal analgesia
                → Lung-protective ventilation
                → Awake extubation head-up

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