Abstract

Regional anaesthesia is often used as a technique of choice for managing both intraoperative surgical procedure and postoperative analgesia in patients with upper extremity injuries. For providing extended pain relief continuous peripheral nerve block (CPNB) is an appropriate anaesthetic technique. The use of CPNB allows rapid establishment of analgesia sufficient for surgical interventions and provides excellent pain control while decreasing the need for opioids and other pain medications after operation.1 We report a successful use of ultrasound-guided supraclavicular CPNB in a case of accidental cut injury to right forearm for intraop surgical procedure and postop analgesia. This case demonstrates the utility of ultrasound-guided CPNB in anaesthetic management of traumatic injuries in which general anesthesia can be precarious due to severe cardiac pathology. We report a case of 30-year-old male with accidental cut injury to middle 1/3rd of right forearm who underwent wound exploration and artery/nerve/tendon repair. During pre-anaesthetic evaluation, he was found to have ‘pulsus parvus et tardes’ and an ejection systolic murmur in aortic and pulmonary areas. Clinically, however, the patient appeared stable with MET score of >4 and gave no history fatigue, shortness of breath or chest discomfort. He was not previously evaluated for any cardiac disorders. The 2D echo done, revealed severe aortic stenosis. Cardiologist was consulted regarding the same, who opined that the patient carries high risk for perioperative adverse cardiac events. Pre-operative VAS as described by the patient was5. Before performing the anaesthetic procedure, patient was sedated with injection Midazolam 2mg and injection Fentanyl 30mcg. Under strict aseptic precautions, skin infiltrated with Inj Lignocaine 2%. Under ultrasound guidance using the in-plane technique, the tip of an 18G tuohy’s needle was positioned at the brachial plexus and a catheter was sited. After negative aspiration, 20ml of Inj Bupivacaine 0.5% was injected. Adequate motor and sensory block was achieved after 15 minutes with VAS, now reduced to, 0. Intra-op, after 4hrs of initial local anaesthetic dose patient complained of pain, top-up of Inj Bupivacaine 0.5%, 5cc was administered. A 5-lead ECG was used for continuous cardiac monitoring for optimal identification of adverse cardiac events. NIBP was used to monitor intraop BP, and since, significant fluid/blood loss was not anticipated in this case, an arterial line wasn’t sited. The surgical procedure was 5 hours long. Vitals were stable throughout. The catheter was removed in the immediately after completion of the procedure before shifting the patient to PACU (post anaesthesia care unit). The patient was monitored in PACU and discharged with an Aldrete score of 9 and VAS of 1. Post-op analgesic effect lasted for 5 hours, after which rescue analgesia (Inj Diclofenac 75mg, slow IV) was administered.

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