High-risk surgeries, anesthetic challenges, and real benefits of peripheral regional techniques revisited

Patients with high-risk conditions for surgery may benefit from some form of regional block when neuroaxial regional blocks may be life threatening. Despite the increased use of ultrasound-guided peripheral regional blocks internationally, local infiltration and targeted nerve blocks aided by knowledge of anatomical landmarks remain helpful in these two patients presented. A 48-year old woman, presented with bleeding left breast mass, mild respiratory distress, and radiological features of lung metastases (Carcinoma of the breast stage 4). Her American Society of Anesthesiologist risk assessment (ASA) was grade 4. Anesthetic technique was mainly local infiltration and intercostal nerve block with 1% lignocaine (10 mg) and 2.5% bupivacaine (62.5 mg) and a 1 in 100,000 dilution of adrenaline in cardiac position with mild sedation with good analgesia and outcome. Another 24-year-old pregnant woman with dilated cardiomyopathy was being managed by a multidisciplinary team. Her cardiac state deteriorated as pregnancy progressed. Caesarean section was done successfully at 35 weeks gestation under local infiltration and rectus sheath block with local anesthetic agents, sedation, and oxygen masks in the cardiac position with good outcome. The good outcomes in these two patients showed the benefit of peripheral regional blocks in high risk patients. Early recognition of high-risk patients and appropriate anesthetic and clinical assessment with the formulation of right techniques can help salvage lives. This thought is more apt in equipment challenged environments like ours in Nigeria, when resources for ultrasound assisted peripheral nerve blocks are not always available.