This patient authorized by signing an informed consent form to describe the case for publication.
We describe the case of a 39-year-old male patient with a diagnosis of giant cell tumor of the left distal femur scheduled by the emergency department for surgical management consisting of transfemoral amputation of the left pelvic limb vs. disarticulation.
Previously healthy patient, his current condition began in January 2020 when he had a motorcycle accident in which he received a contusion in the left thigh, which evolved into continuous stabbing pain, VAS 6/10, located at the level of the distal third of the left thigh, which improved with non-steroidal anti-inflammatory, then presented progressive increase in volume for four months, subsequently presented progressive increase in volume for four months and was evaluated by a physician. An incisional biopsy was performed in May 2022 which reported an aneurysmal bone tumor and was sent to our institute for management.
He was admitted to the institute for surgical management, however when he obtained a positive result of SARS COV 2 (figure 1), he was rescheduled. Ten days later he presented in the emergency room in a wheelchair with fever, intense pain, foul odor and hematopurulent exudate in the tumor of the left femur (figure 2). On physical examination the patient was found conscious, oriented, cooperative, on physical examination directed, left pelvic extremity with increased volume in the distal third of the left thigh (++++/++++) with a circumference of 59 cm against 42 cm of the contralateral, soft consistency tumor, with erythematous lesion with purulent exudate measuring 10 x 10 cm, knee mobility arches abolished, ankle mobility arches preserved only posterior tibial activity performing plantar flexion of 10 degrees and abduction of the forefoot, sensitivity of the entire limb without alteration with respect to the contralateral, normal distal capillary filling. MRI of left pelvic extremity showing hyperintense image in distal third of femur and knee, lobulated, expansive, with involvement of soft and bony tissues of 13.4x19 cm in diameter (Figure 3).
He was scheduled for urgent surgery. Labs on admission: leukocytes 13,000, hemoglobin 8.9, hematocrit 28.5%, platelets 266,000, Tp 11.6, Ttp 27.6, INR 1.08. Fibrinogen 485, glucose 100, creatinine 0.57.
The management of the anesthetic technique was performed with: intravenous (IV) sedation plus subarachnoid block (SAB) plus erector spinae plane block (ESP).
After signing the informed consent form, the patient was admitted to the operating room, weight 70 kgs, height 160 cm, BMI 27.3 kg/m2. Peripheral venous catheter holder 16 G in left forearm permeable. Type I monitoring was placed, PANI 113/65 mmHg, HR 116 bpm, SpO2 96%, oxygen was placed through nasal prongs at 2 bpm. Administration of IV coadjuvant drugs was started: cephalothin 1 g, parecoxib 40 mgs, paracetamol 1 g, metoclopramide 10 mgs, dexamethasone 4 mgs, sedation with midazolam 1.5 mg IV plus fentanyl 100 mcg IV. Asepsis of the right neck region was performed, a linear transducer was placed with sterile technique, it was approached out of the plane with a needle up to the jugular vein, a guide was placed, an increase in the amplitude of the P wave was observed in the electrocardiogram (18), 1 cm was removed, a 3 lumen catheter was placed, it was fixed to the skin, a control X-ray was taken where it was observed in the cavo atrial junction. The patient was placed in right lateral decubitus, asepsis of the dorsolumbar region was performed, the patient was punctured with a #25 Quincke needle at L3-L4 level up to the subarachnoid space, clear cerebrospinal fluid was obtained, bupivacaine 12.5 mgs was administered, the needle was removed without incident. Latency 5 minutes, linear transducer was placed with sterile technique, transverse process was identified at L4 level, since at this level we expect a dispersion of two to three levels above and below, 100 mm ultrasound-guided needle was approached up to transverse process of L4, dose of ropivacaine 112.5 mgs at 0.5% total volume of 20 ml was administered, adequate cephalocaudal dissemination of local anesthetic was observed under the erector spinae muscle. Sedation was maintained with dexmedetomidine infusion at 0.5 mcg/kg/hr. During transanesthesia hemodynamically stable, with spontaneous ventilation. Surgical time of 3 hours.
In the recovery area the patient was monitored and pain was evaluated with a numerical scale from 0 to 10 (0 no pain and 10 the worst pain imaginable). At 3 hours the patient reported pain 2/10 . At 8 hours he reported pain 4/10, paracetamol 1 g orally plus ketorolac 30 mg IV was started and he reported improvement. That same day he was also started on gabapentin and amitriptyline. He was followed up by the anesthesiologist who was in charge of him in the operating room during the following 72 hours. Without reporting pain above 6 at any time, he continued with the dose of paracetamol and ketorolac every 8 hrs, at rest reporting an ANE of 0/10 and on movement of 2/10, at 48 hrs he walked with crutches and was discharged at 72 hrs without complications.