50th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

Management of Complex Resection of Left Shoulder Chondrosarcoma Using a Combined Epidural and Continuous Nerve Block Catheter Approach

Derek Nie, MD1, Vikram Bhasin, MD1, 2

1Department of Anesthesiology, Montefiore Medical Center and

2Albert Einstein College of Medicine

Introduction

•Primary and metastatic bone malignancies are not uncommon in adults, but there have been relatively few discussions in the literature regarding anesthetic management of orthopedic oncologic surgeries (1).

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•Chondrosarcoma is the most common bone sarcoma in adults, with an incidence of 8 per million people, mostly affecting patients greater than age 50 (1).

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•These cases can be particularly challenging due to complexity, case length, positioning, minimizing blood loss, and coordinating effective analgesic plans.

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•For tumor resection of the upper extremity, a combination of brachial plexus nerve block as well as an indwelling nerve catheter provides excellent surgical anesthesia and postoperative analgesia (1).

Case Presentation

•The patient was a 63-year-old female with a past medical history of hypertension, chronic kidney disease (stage 3a) and anemia, with a rapidly growing left shoulder chondrosarcomatous malignant neoplasm, with additional smaller masses in the third costal cartilage and at the top of the left axilla, extending into the chest wall.

•The patient received a biopsy that confirmed a low-grade chondrosarcoma, and given its rapid growth and extensive anatomic malignancy, presented for left forequarter amputation with resection of the involved sternum and anterior left ribs

•In the pre-operative area, the patient received an ultrasound guided single shot left sided interscalene block, with injection of 20 mL of bupivacaine 0.5%.

Intraoperative Course

•After proceeding to the operating room, the patient received sedation with intravenous midazolam and fentanyl. A T4 thoracic epidural was placed with a 9cm length 17G Tuohy needle, loss of resistance confirmed with saline, and a 19G catheter threaded to a depth of 12cm. General anesthesia was induced and the patient was intubated, a 7 Fr bronchial blocker was placed in the right main bronchus, a right radial arterial line placed, and a right internal jugular central line was placed.

•A foley catheter was placed. Cefazolin was given for antibiotic prophylaxis and subcutaneous heparin was given for perioperative thromboprophylaxis. The patient was positioned supine, with the right arm tucked, and a shoulder roll placed. One-lung ventilation was started.

•Dissection extended from the right sternoclavicular joint to the first rib. During this extensive dissection, bupivacaine 0.125% boluses and a 6 mL/hr infusion of 0.125% bupivacaine with 2 mcg/mL of fentanyl were given via thoracic epidural for analgesia.

•The drapes were removed and the patient was repositioned into the right lateral decubitus position. A large fasciocutaneous flap was performed. The left subclavian vessels were ligated and 2 units of packed red blood cells, 5% albumin, calcium chloride, and a phenylephrine infusion were given for resuscitation.

•The drapes were removed and the patient was repositioned to be supine, with a shoulder roll and the right arm tucked. The right clavicle was fixed to the remnant sternum with a plate. A chest tube was placed. A nerve block catheter was placed by the surgical team in the open surgical field in a retrograde manner, so the tip ended at the transected brachial plexus. A chest wall reconstruction was performed.

Postoperative Course and Discussion

POSTOPERATIVE COURSE

•The patient left the operating room intubated and was transferred to the surgical intensive care unit in stable condition. Ropivacaine 0.2% at 6 mL/hr was started via the nerve block catheter and the epidural infusion was continued at the intraoperative rate of 6 mL/hr,

•No post-operative opioids required. Pain scores were between 0/10 to 2/10.

•The patient was weaned to pressure support ventilation over the first 24 hours and extubated to high flow nasal cannula on postoperative day 2.

•The epidural was removed on post-operative day 6 and the nerve block catheter was removed on post-operative day 7.

DISCUSSION

•Orthopedic oncologic surgeries can be particularly challenging for anesthetic management due to case complexity, length, positioning, blood loss and management of post-operative pain (1). Intraoperative boluses and infusion via the thoracic epidural contributed significantly to analgesia while not compromising hemodynamic stability

Epidural infusion has been shown to provide superior postoperative pain control compared to intravenous patient-controlled analgesia (2). Postoperatively, the epidural infusion and peripheral nerve block catheter infusionprovided effective analgesia for over a week postoperatively.

References

1.Anderson MR, Anesthesia for patients undergoing orthopedic oncologic surgery. Journal of Clinical Anesthesia 2010; 22:565-572.

2.Weinbroum AA, Superiority of postoperative epidural over intravenous patient-controlled analgesia in orthopedic oncologic patients. Surgery 2005;138(5):869-76.

50th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

MANAGEMENT OF COMPLEX RESECTION OF SHOULDER CHONDROSARCOMA USING A COMBINED EPIDURAL AND CONTINUOUS NERVE BLOCK CATHETER APPROACH

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