Ultrasound-Guided Dual Plexus Blockade with Light Dexmedetomidine Sedation for Clavicle Fixation after Decompressive Craniectomy: An Observational Analytic Case Study

Abstract

Background. Non-neurosurgical surgery soon after traumatic brain injury (TBI) and decompressive craniectomy risks secondary brain injury. Few reports describe regional anesthesia as the primary technique in this setting.

Objective. To describe the anesthetic management and hemodynamic course of a patient who had clavicle fixation under ultrasound-guided interscalene and superficial cervical plexus blocks with dexmedetomidine sedation after craniectomy.

Methods. This CARE-guided report describes a 24-year-old man (ASA physical status III-E) who needed fixation of a displaced mid-shaft clavicle fracture six days after craniectomy for a 70 mL epidural hematoma. He received an interscalene block (15 mL) and a superficial cervical plexus block (10 mL) of 0.375% levobupivacaine, and dexmedetomidine 0.4 μg/kg/hr without a bolus. Arterial pressure and heart rate were recorded at 11 time points. Cerebral perfusion pressure (CPP) was estimated as mean arterial pressure (MAP) minus an assumed intracranial pressure of 10–12 mmHg.

Results. Surgery lasted 150 minutes without airway instrumentation or vasoactive drugs. MAP ranged from 83.3 to 93.3 mmHg (lowest 83.3 mmHg at skin closure, −10.7% from baseline) and estimated CPP from 73.3 to 81.3 mmHg. The rate-pressure product fell from 10,496 to 8,024–9,375 bpm·mmHg after the block. Diaphragmatic excursion exceeded 1.8 cm. No rescue opioid was needed. The patient was discharged on postoperative day 2 with a Glasgow Coma Scale score of 15.

Conclusion. The technique was feasible. Arterial pressure stayed stable. Intracranial pressure was not measured, and dexmedetomidine probably contributed, so the case cannot show neuroprotection; it supports prospective study.