Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)

Background and Aims Proper pain management in patients undergoing Anterolateral Tigh (ALT) flap surgery is crucial to minimize early postoperative complications. We present a case of a 58-year-old male admitted for partial pelviglossectomy, mandibulectomy and ALT of the left limb, who received both limbs a femoral nerve block due to insufficient Doppler flowmetry on the limb first chosen by the surgeons. We aim to demonstrate that a pre-emptively femoral nerve block can be part of a multimodal analgesic strategy in these patients and that a second non-planned nerve block can be safely performed if the maximum dose of local anesthetic is taken into consideration.

Methods A total intravenous anesthesia with propofol and remifentanil was induced and a single-shot, ultrasound-guided, right and left femoral nerve blocks were performed using 15 ml of 0,75% ropivacaine on each side. A total of 30ml (225 mg) was administered – a safe dose of ropivacaine for an 80kg patient. The maintenance dose of remifentanil was low (up to less than 0,05-0,10 mcg/kg/min) and analgesia was complemented with ketorolac 30mg, paracetamol 1g and morphine 2mg.

Results There were no signs of local anesthetic systemic toxicity (LAST) and the patient was admitted to the post-anesthetic care unit after 10h of surgery without pain in the flap area, 0/10 (numerical rating scale pain) at rest and movement. Pain at rest was only reported more than 24h after the block.

Conclusions This case enhances the importance of performing vascular Doppler signals before anesthetic nerve blocks to avoid unnecessary blocks and risk for LAST.