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Abstract
Please confirm that an ethics committee approval has been applied for or granted: Not relevant
Background and Aims Achieving surgical anesthesia for above the knee amputation (AKA) utilizing peripheral nerve blocks (PNB) is challenging due to the complex innervation of the thigh compartment. At present, there is limited literature on the use of PNB as the sole anesthetic technique for AKA. This paper presents a case of a 61-year-old female and known case of Neurofibromatosis Type 1 who was scheduled for AKA due to a malignant peripheral nerve sheath tumor in the right patellar area (figure 1). The tumor was causing anemia and sepsis due to active bleeding and infection. The patient also developed hospital-acquired pneumonia.
Methods The patient was started on Midazolam and Fentanyl followed by target-controlled infusion of Propofol for sedation. Five nerve blocks were performed: femoral, lateral femoral cutaneous, obturator, subgluteal sciatic, and posterior femoral cutaneous. Ultrasound, nerve stimulator, and pressure monitor guidance was utilized. The concentration and volume of Ropivacaine was adjusted based on the patient’s weight (38 kg). A femoral nerve catheter was placed post-operatively for supplemental pain control.
Results The patient was hemodynamically stable throughout the procedure, with no recall of intra-operative events including the conduct of nerve blocks. She had good post-operative pain control and was subsequently discharged on the fifth post-operative day.
Conclusions This case report highlights PNB as a safe and effective anesthetic technique for AKA in patients with contraindications to neuraxial and general anesthesia. Specific block of the posterior femoral cutaneous nerve (figure 2), which was not described in past literature on PNB for AKA, was performed in this case.
Malignant peripheral nerve sheath tumor on patellar area of right leg. Multiple cutaneous neurofibromas can also be appreciated
Ultrasound imaging of the posterior femoral cutaneous nerve at the subgluteal level. PFCN: Posterior Femoral Cutaneous Nerve; SN: Sciatic Nerve; BF: Biceps Femoris; GT: Greater Trochanter; GM: Gluteus Maximus