Case Summary

A 42-year-old right-handed male sustained a crush injury to his right hand when bricks fell, resulting in a near-total amputation of the right middle finger with vascular compromise. The time from injury to surgical assessment was less than three hours. Emergency debridement and revascularization were planned. Because of the urgency of intervention, general anesthesia (GA) was chosen over a brachial plexus block. A wrist block was administered as an adjunct for postoperative analgesia. Tourniquet control was necessary to provide a bloodless surgical field.

Airway management was initiated with an i-gel supraglottic airway. Once the surgical team confirmed the plan for microsurgical neurovascular reconstruction, the airway was upgraded to an 8.0 mm internal diameter endotracheal tube to secure ventilation during the anticipated six-hour procedure. A Foley catheter was inserted intraoperatively to enable accurate monitoring of fluid balance and urine output.

Reasons for Choosing General Anesthesia

Time Sensitivity

Revascularization in crush injuries is highly time-dependent. With less than three hours since the injury, any delay caused by block placement and assessment could jeopardize tissue salvage.

Dominant Hand Involvement

The right hand was affected, and being the dominant hand, the injury caused severe discomfort. This reduced the likelihood of patient cooperation with a regional block. General anesthesia ensured immobility and reliable surgical conditions.

Prolonged Microsurgery

The surgeons anticipated complex neurovascular reconstruction with an expected duration of six hours. Endotracheal intubation provided secure airway management and reliable ventilation throughout the prolonged surgery.

Requirement for Intraoperative Catheterization

Accurate fluid balance monitoring and urine output assessment were necessary during this long surgery. GA facilitated catheterization under comfortable and controlled conditions.

Tourniquet Application and Systemic Effects

General anesthesia offered better control over hemodynamic responses to tourniquet inflation and deflation. It also allowed pre-emptive management of systemic metabolic disturbances, including acidosis and hyperkalemia.

Adjunct Regional Analgesia

A wrist block targeting the median, radial, and ulnar nerves was performed to provide postoperative analgesia, reduce systemic opioid requirements, and improve comfort.

References

Hadzic A. Textbook of Regional Anesthesia and Acute Pain Management. McGraw Hill; 2007.

Neal JM, Brull R, Horn JL, et al. The risks of peripheral nerve blocks. Reg Anesth Pain Med. 2015;40(5):389–405.

McLaren AC. Tourniquet use in surgery. J Bone Joint Surg Am. 1991;73(10):1379–1381.

Swiontkowski MF, et al. Timing of surgical intervention for limb revascularization. J Bone Joint Surg Am. 1994;76(1):67–75.

Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK. Br J Anaesth. 2011;106(5):617–631.

Key Anesthetic Challenges

Although the trauma was localized to a single digit, the severity of the crush injury and vascular compromise raised systemic concerns. Crush injuries, particularly when combined with tourniquet application and revascularization, can trigger systemic inflammatory and metabolic consequences.

Key risks include:

• Cellular rupture with release of potassium, myoglobin, and inflammatory mediators.
• Rhabdomyolysis due to deep muscle damage or reperfusion injury.
• Acidosis and hyperkalemia following tourniquet deflation or reperfusion, with potential cardiac complications.
• Renal compromise due to myoglobinuria, hypovolemia, or intraoperative hypotension.

These factors require vigilance for features of crush syndrome even in apparently localized injuries.

References

Bywaters EG, Beall D. Crush injuries with impairment of renal function. BMJ. 1941;1(4185):427–432.

Better OS, Stein JH. Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med. 1990;322(12):825–829.

Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters. N Engl J Med.2006;354(10):1052–1063.

Smith J, Greaves I. Crush injury and crush syndrome. Emerg Med J. 2003;20(5):406–408.

Intraoperative Anesthesia Management

Premedication

• Glycopyrrolate 0.2 mg IV: Reduced vagal tone and secretions.
• Midazolam 1 mg IV: Provided anxiolysis and amnesia.
• Fentanyl 100 mcg IV: Offered analgesia and blunted sympathetic responses.

Induction and Neuromuscular Blockade

• Dexamethasone 8 mg IV: Minimized edema and provided antiemetic cover.
• Propofol 150 mg IV: Smooth and rapid induction with antiemetic properties.
• Atracurium 40 mg IV, maintained at 10 mg/hr infusion, was selected for its Hofmann degradation. The infusion was discontinued more than 25 minutes before reversal.

Airway Management

An i-gel was initially inserted for rapid control, later replaced with an 8.0 mm endotracheal tube for secure ventilation during prolonged microsurgery.

Intraoperative Monitoring

• Foley catheterization enabled fluid balance and renal monitoring.
• Serial blood pressure, urine output, and tourniquet times were meticulously recorded.

Maintenance and Analgesic Adjuncts

• Dexmedetomidine 30 mcg IV: Sedation and MAC-sparing effect.
• Magnesium sulfate 1 g IV: NMDA antagonism and analgesic augmentation.
• Paracetamol 1 g IV and diclofenac 100 mg suppository: Multimodal non-opioid analgesia.
• Morphine 5 mg IM at closure: Long-acting analgesic support.

Regional Analgesia

A wrist block targeting the median, radial, and ulnar nerves was administered for postoperative pain relief and reduction of tourniquet discomfort.

Tourniquet Protocol

Standardized inflation pressures, proper limb elevation, and strict time monitoring minimized systemic ischemia-reperfusion risks.

References

Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s Clinical Anesthesiology. 6th ed. McGraw Hill; 2018.

Lee CR, Kim JH, Jeon YT. Magnesium sulfate supplementation enhances postoperative analgesia. Korean J Anesthesiol.2012;62(6):520–526.

Reves JG, Fragen RJ, Vinik HR, Greenblatt DJ. Midazolam: pharmacology and uses. Anesthesiology. 1985;62(3):310–324.

Mirakhur RK. Neuromuscular blocking drugs: properties and clinical applications. Anaesthesia. 1991;46(5):359–371.

Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: 4th National Audit Project. Br J Anaesth. 2011;106(5):617–631.

Key Learning Points

• Emergency replantation requires rapid and safe anesthetic choices to optimize microsurgical outcomes.
• General anesthesia was appropriate given the urgency, severe pain in the dominant hand, and complexity of vascular reconstruction.
• Endotracheal intubation provides reliable airway protection and ventilation in long-duration microsurgery.
• Regional blocks complement GA by improving analgesia, reducing opioid consumption, and addressing tourniquet discomfort.
• Foley catheterization is essential for prolonged surgeries to monitor renal function and guide fluid therapy.

References

Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg.1993;77(5):1048–1056.

Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey. Anesth Analg.2003;97(2):534–540.

Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg. 2011;113(4):904–925.

Cook TM, et al. Major airway complications in anesthesia practice. Br J Anaesth. 2011;106(5):617–631.