Anesthetic and Surgical Management of a Patient with The Risk of Anaphylaxis: Patient Safety and Performance of Alternative Axillary Brachial Plexus Block

Abstract

BACKGROUND: Anaphylaxis during general anesthesia (GA) is rare; but increases morbidity and mortality. The investigation of suspected anaphylaxis is challenging since the patient is often exposed to a number of drugs within a few minutes.
CASE: Fortytwo years-old female, ASA II patient had multiple drug allergy (propofol, meperidine, bupivacaine, cefazolin, amoxiciline-clavulanate, metronidazole, flurbiprophen, levofloxacin, diclophenac). She previously had 9 operations under GA and experienced anaphylaxis culminating in internal care unit administration in two of them. She was scheduled for reconstruction of deep flexor tendon injury with plantar tendon graft of the left foot. However; GA or the combination of axillary brachial plexus and sciatic nerve block options were not seemed appropriate when the block failure, local anesthetic toxicity and anaphylaxis risks were taken into account. Therefore, the surgical plan was switched to the transfer of palmaris longus tendon of the left hand and the anesthesia decision was made to perform only axillary brachial plexus block with non-allergic agents.
After sedation; axillary artery, vein, median, ulnar, radial and musculocutanous nerves were visualized with the high frequency linear probe in the axillary region. Twentyone mL (10mL 2% lidocaine(200 mg), 10mL 2% prilocaine(200 mg) and 1mL adrenaline(100 mcg)) was administered by using in-plane technique. After the adequate block, operation was completed uneventfully. The patient had only 500mg of IV paracetamol twice during the first 24hours postoperatively(NRS≤5).
CONCLUSION: This case is presented to emphasize that anesthesia and surgical team communication and the use of alternative anesthesia techniques improve patient safety.