181 The application of a combination of interscalene and paravertebral blocks in a patient with a pathological humerus fracture: a case report

Background and Aims Most amputation procedures at the shoulder joint, on patients suffering from pathological humerus fractures are performed under general anesthesia.Here we show a case of an American Society of Anesthesiologists classification (ASA) III patient, scheduled for amputation of the humerus, at the shoulder joint. Due to a high risk procedure under general anesthesia, we decided to apply interscalene and paravertebral blocks along with intravenous sedation. Methods A 55-year-old male, ASA III patient, was scheduled for amputation of his right humerus. The patient had a history of bladder cancer with multiple metastases on the lungs, lymph nodes and bones. He also suffered from a pathological fracture of left humerus, with presence of left-hand cellulitis. During preparation for surgery, an invasive blood pressure measurement was set up, while the interscalene and paravertebral spaces were identified using a nerve-stimulating needle and a linear ultrasound probe of 8 and 12 Hertz. An anesthetic solution of 0.5% levobupivacaine was applied at Thoracic (Th) 2 and Th3 levels (5 milliliters per level) and to the brachial plexus (20 milliliters). We used 1% lidocaine for skin infiltration and sedation was performed with a continuous infusion of 1% propofol. Results Sensory blockade occurred after 18 minutes and lasted for about 16 hours in the shoulder and 10 hours in the axilla region, with stable hemodynamic parameters and no perioperative complications. Conclusions Such precise administration of small doses of long-acting local anesthetic at multiple levels has resulted in a satisfactory anesthesia and analgesia without hemodynamic and respiratory complications.