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Case Reports  |   November 2001
The Use of Hypotensive Technique in Conjunction with Brachial Plexus Block Anesthesia for Surgery of the Upper Extremity
Author Affiliations & Notes
  • Anil S. Ranawat, B.S.
    *
  • Edwin P. Su, M.D.
  • Joseph M. Lane, M.D.
  • Nigel E. Sharrock, M.B., Ch.B.
    §
  • * Student, Weill Medical College, Cornell University. † Orthopaedic Resident, The Hospital for Special Surgery. ‡ Chief, Metabolic Bone Service, § Senior Scientist, Department of Anesthesiology, The Hospital for Special Surgery.
  • Received from Weill Medical College, Cornell University, New York, New York, and The Hospital for Special Surgery, New York, New York.
Article Information
Case Reports
Case Reports   |   November 2001
The Use of Hypotensive Technique in Conjunction with Brachial Plexus Block Anesthesia for Surgery of the Upper Extremity
Anesthesiology 11 2001, Vol.95, 1294-1295. doi:
Anesthesiology 11 2001, Vol.95, 1294-1295. doi:
SURGERY to internally fix pathologic fractures of the humerus may result in substantial blood loss for several reasons. For one, it is difficult to apply an effective tourniquet because of the proximal location of many of these lesions. Furthermore, pathologic humeral lesions may be highly vascular, leading to bleeding when excised. 1,2 We report the use of hypotensive anesthesia, in conjunction with interscalene block anesthesia, to manage surgery in a patient with such a lesion.
Case Report
The patient is a 70-yr-old man (95 kg, 170 cm) who had a pathologic fracture to his left humerus. His medical history was notable for renal stones, benign prostatic hypertrophy, and gout, all of which were well- controlled. His only medication was allopurinol. His physical exam was remarkable for decreased range of motion of the left arm, due to pain. He had normal motor and sensory function of left wrist flexors and extensors. The radiographic films of the left humerus revealed a pathologic fracture of the shaft with a 2-cm, round, lytic lesion in the proximal humeral diaphysis (fig. 1). A bone scan revealed uptake in the region of the pathologic fracture, as well as symmetric uptake at the acromioclavicular and sacroiliac joints thought to be consistent with degenerative arthritis. All preoperative blood work was normal except for lactate dehydrogenase level of 561 U/l. His preoperative blood pressure was 150/80 mmHg, with a heart rate of 70 beats/min.
Fig. 1. Preoperative anteroposterior radiograph of the left humerus demonstrating lytic lesion in the proximal one-half diaphysis, with pathologic fracture.
Fig. 1. Preoperative anteroposterior radiograph of the left humerus demonstrating lytic lesion in the proximal one-half diaphysis, with pathologic fracture.
Fig. 1. Preoperative anteroposterior radiograph of the left humerus demonstrating lytic lesion in the proximal one-half diaphysis, with pathologic fracture.
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An interscalene block was performed before the administration of sedation by seeking a shoulder paresthesia with a 23-gauge needle. A mixture of 30 ml mepivacaine (1.5%), 20 ml bupivacaine (0.75%), and 200 μg epinephrine was injected in divided doses. Within 2 min, the pain in the arm resolved and the patient was sedated and put in the lateral decubitus position. Inflatable Shoulder-Floats (Trimline Medical Products, Branchburg, NJ) were placed beneath the chest wall and head to decompress the dependent shoulder and keep the neck aligned. Lateral stability was maintained with a bean bag. The patient was sedated with a mixture of intravenous fentanyl (100 μg/h) and propofol (200 mg/h). A 20-gauge catheter was then inserted into the dependent radial artery. Hypotension was induced with 20 mg hydralazine. Mean arterial pressure decreased from 90 mmHg to approximately 55 mmHg. Thirty minutes later, 2 mg metoprolol was given intravenously in divided doses, which reduced the heart rate from 80 to 70 beats/min. Mean arterial pressure and heart rate remained stable thereafter. Sao2was 97–98% throughout surgery, with the patient receiving nasal oxygen at 3 l/min.
An approximately 17-cm-long incision was made posteriorly from the triceps insertion continuing proximally. The radial nerve was dissected out and visualized. The pathologic fracture site was identified and a frozen section revealed a plasmacytoma. The fracture was fixed with a plate and screws. Bone cement mixed with tobramycin was then placed into the bone defect for additional stability, followed by copious irrigation and closure. Intraoperative blood loss was estimated to be 400 ml and 1,500 ml lactated Ringer’s intravenous fluid was administered.
The patient’s course that evening in the postanesthesia care unit was uneventful, and he was soon transferred to the floor with an intravenous morphine patient-controlled analgesia. On postoperative assessment later that evening, he was found to be comfortable, with some residual decreased sensation in the hand as well as weakness of his wrist extensors. On postoperative day 1, the patient had complete return of sensory and motor function. He received a total dose of 30 mg intravenous morphine via patient-controlled analgesia, which was initiated 4.5 hours after surgery. Approximately 30 h after starting his intravenous morphine patient-controlled analgesia, he was converted to oral analgesics. His preoperative hemoglobin was 15.8 mg/dl, and 13.1 mg/dl the next day. He did not require any transfusion of blood products. He was discharged after an uneventful hospital course on postoperative day 4.
Discussion
Conventional anesthetic approaches in this case would include brachial plexus block with normotension or general anesthesia with either normotension or induced hypotension. As a tourniquet was likely to encroach upon the surgical field, it was decided that intraoperative hypotension would be a better alternative to reduce the possibility of significant blood loss during surgery. Induced hypotension for upper extremity surgery is typically performed with general anesthesia. 3 One of the appeals of a brachial plexus block is that it is easier to control pain immediately after surgery. By inducing intraoperative hypotension with a brachial plexus block, we were able to achieve the benefits of control of bleeding during surgery with effective pain control immediately after surgery.
Hypotension was readily induced by using hydralazine with only a slight compensatory tachycardia. Heart rate was maintained throughout surgery at approximately 70 beats/min and mean arterial pressure 55 mmHg after the administration of apresoline and metropolol. Thereafter, stability was maintained with little intervention other than intravenous sedation with propofol and crystalloid administration. This may have been partly because of effective sedation and optimal patient positioning, as well as an intense brachial plexus blockade. In addition, an interscalene block may partially block the cardiac accelerator nerve to the sinus node, 4 minimizing the tendency to reflex tachycardia with hypotension.
Induced hypotension in elderly patients with vascular comorbidities during general anesthesia remains controversial. 3 By contrast, induced hypotension (mean arterial pressure 45–55 mmHg) with extensive epidural blockade in the elderly and in patients with hypertension or atherosclerotic heart disease appears to be safe when properly administered. 5–7 On the other hand, a well- conducted general anesthetic with induced hypotension in elderly high-risk patients lying flat may be equally safe, although this is yet to be documented in large series of patients.
This patient recovered well from the surgery, requiring no blood transfusion and moderate doses of narcotic postoperatively. Induced hypotension in combination with brachial plexus block may be a useful approach in selected cases such as this.
References
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Yazawa Y, Frassica FJ, Chao EY, Pritchard DJ, Sim FH, Shives TC: Metastatic bone disease: A study of the surgical treatment of 166 pathologic humeral and femoral fractures. Clin Orthop 1990; 251: 213–9Yazawa, Y Frassica, FJ Chao, EY Pritchard, DJ Sim, FH Shives, TC
Van Aken H, Miller ED Jr: Deliberate Hypotension, Anesthesia. Edited by Miller RD. New York, Churchill Livingstone, 2000, pp 1470–90
Opie LH: Autonomic nervous system. Beta- and alpha-adrenoceptor antagonism, The Heart: Physiology, Metabolism, Pharmacology and Therapy. New York, Harcourt Brace Jovanovich, 1984, pp 213–29
Sharrock NE, Mineo R, Urquhart B: Haemodynamic effects and outcome analysis of hypotensive extradural anaesthesia in controlled hypertensive patients undergoing total hip arthroplasty. Br J Anaesth 1991; 67: 17–25Sharrock, NE Mineo, R Urquhart, B
Williams-Russo P, Sharrock NE, Mattis S, Liguori GA, Mancuso C, Peterson MG, Hollenberg J, Ranawat C, Salvati E, Sculco T: Randomized trial of hypotensive epidural anesthesia in older adults. A nesthesiology 1999; 91: 926–35Williams-Russo, P Sharrock, NE Mattis, S Liguori, GA Mancuso, C Peterson, MG Hollenberg, J Ranawat, C Salvati, E Sculco, T
DiGiovanni CW, Restrepo A, Della Valle AG, Sharrock NE, McCabe JP, Sculco TP, Pellicci PM, Salvati EA: The safety and efficacy of intraoperative heparin in total hip arthroplasty. Clin Orthop 2000; 379: 178–85DiGiovanni, CW Restrepo, A Della Valle, AG Sharrock, NE McCabe, JP Sculco, TP Pellicci, PM Salvati, EA
Fig. 1. Preoperative anteroposterior radiograph of the left humerus demonstrating lytic lesion in the proximal one-half diaphysis, with pathologic fracture.
Fig. 1. Preoperative anteroposterior radiograph of the left humerus demonstrating lytic lesion in the proximal one-half diaphysis, with pathologic fracture.
Fig. 1. Preoperative anteroposterior radiograph of the left humerus demonstrating lytic lesion in the proximal one-half diaphysis, with pathologic fracture.
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