Anaesthetic management of a case of hand replantation under continuous supraclavicular

block

INTRODUCTION ANAESTHETIC CONCERNS

• Using a 18 G intravenous cannula , 30ml of local • The major anaesthetic considerations are,
• Hand microsurgeries are procedures performed by anaesthetic mixture (containing 10ml of 0.5% • Time: replantations are generally time-consuming procedures,
reconstructive surgeons and require a complex and 1. Patient was not fasting hence had very high risk for bupivacaine, 10 ml of 2% lignocaine diluted with 10ml with multiple digital replants often taking up to 12–18 h or longer
highly individualized approach. and patients usually present with inadequate fasting status.
aspiration during general anaesthesia of sterile water mixed with Inj.epinephrine 100mcg)
• Vasospasm/thrombosis: these potentially catastrophic events
• The emergency nature of the procedure and 2. There was very limited time for preoperative was injected perineurally around the brachial plexus. can lead to loss of the replanted digit/ limb . Interventions to
prolonged duration pose challenge to the optimisation • Finally the 18G cannula was placed near the proximity reduce the risk of these include the maintenance of strict
anaesthesiologist. 3. Single shot brachial plexus block would not last the of the middle of brachial plexus using ultrasound normothermia once the arterial anastomosis begins,
avoidance of vasoconstrictor agents maintenance of the
• Continuous peripheral nerve blocks (CPNBs) provide duration of surgery guidance and the stylet removed. hematocrit at approximately 30% to improve viscosity and
a number of advantages in the perioperative period. 4. Microcatheters or specialised catheters for • The total duration of surgery lasted for 10 hrs. microcirculation, and sympatholysis by the use of
These techniques provide the flexibility to prolong sympathetic or brachial plexus blocks. In addition, most
continuous regional blocks could not be procured Intraoperative vitals were stable. Patient was infused
microsurgical teams use some combination of aspirin, heparin
intraoperative anesthesia while avoiding the risks and with 3 litres of crystalloid intraoperatively and the total and dextran to counteract the hypercoagulable response to
side effects of general anesthesia.  urine output was 1.5 litres. trauma.
• Intermittent boluses of 8ml of 0.125% bupivacaine • Pain control: quality analgesia with regional anesthesia plus a
multimodal adjuvant regimen will decrease the stress response
CASE HISTORY was given through the supraclavicular catheter on an and reduce the risk of thrombosis and vasospasm.
hourly basis after 5 hrs of initial blockade. • LAST: the patient must be monitored for signs and symptoms of
• A 39 year old female with history of road traffic • Intravenous sedation with inj.fentanyl and local anaesthetic systemic toxicity throughout the perioperative
period
accident presented with a total crush amputation at inj.midazolam along with local site infiltration was
middle one third level of left forearm. The patient used for split skin grafting. CONCLUSION
presented to hospital within two hours , the severed • Patient was comfortable throughout the intraoperative
limb was brought along with. period and no complications were observed. • Hand amputation with avulsion/ crush injury is one of the
• The patient was conscious and able to converse but • After surgery patient was shifted to ICU , challenging presentations in anaesthesia. Continuous
was very anxious. Supraclavicular catheter was kept in situ for further supraclavicular brachial plexus block using a standard
• The ambulance crew had estimate approximately 500 post operative analgesia . intravenous catheter is a good choice considering the
ml of blood loss in the field, and no other associated emergent nature and prolonged duration of the procedure.
injuries.
• She was healthy otherwise, had no allergies and took
no medications. The patient had eaten a solid meal
just 3 hours prior. REFERENCES
• Vitals were BP 130/86 mmHg, HR 102 bpm, RR ANAESTHETIC MANAGEMENT
20/min, temperature 36.5°C and SpO2 99% on • ULTRASOUND GUIDED CONTINUOUS 1. Arbona, F., Khabiri, B., Norton, J., Hamilton, C., & Warniment, K.
facemask oxygen. SUPRACLAVICULAR BLOCK WAS THE CHOSEN (2011). Supraclavicular continuous perineural catheter.
• She was scheduled to be transferred urgently to the ANAESTHETIC PLAN In Ultrasound-Guided Regional Anesthesia: A Practical Approach to
Peripheral Nerve Blocks and Perineural Catheters (pp. 152-159).
operating room for debridement and replantation of the • The patient was shifted to the operating room , Cambridge: Cambridge University Press.
severed limb. monitors were attached and baseline vitals recorded. 2. Gadsden, J. (2012). Regional anesthesia and digital replantation.
DISCUSSION
• The surgeons wanted to do a end to end repair which IV access was secured. In Regional Anesthesia in Trauma: A Case-Based Approach (pp.
was expected to last for about 8-10 hours. 19-25). Cambridge: Cambridge University Press.
• Under strict aseptic precautions, patient in supine doi:10.1017/CBO9781139060202.006
position, the skin was disinfected . Ultrasound guided • The principal goals of upper limb, hand or finger 3. Poonam Darswal, Deepak Soni, Rakesh Sehrawat, Dr. Shipra, USE
supraclavicular brachiall plexus block was performed replantation are to restore circulation and to regain OF STANDARD INTRAVENOUS CANNULA FOR CONTINUOUS
by placing the transducer positioned in transverse enough function and sensation in the amputated part SUPRACLAVICULAR BLOCK FOR THUMB
REIMPLANTATION, BJA: British Journal of Anaesthesia, Volume
plane. so as to facilitate return to previous employment 107, Issue eLetters Supplement, 23 December 2011,
and/or activities of daily living.

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