Regional anesthesia combined with intravenous sedation in a patient with Down syndrome undergoing major humerus surgery: case report.

Abstract

Introduction

Down syndrome (DS) is the most common genetic disorder in humans and is associated with multiple conditions that persist and worsen with age, including microcephaly, macroglossia, atlantoaxial instability, subglottic stenosis, congenital heart disease, autonomic dysfunction, obstructive sleep apnea, and hearing loss. In addition, these patients may have difficulties in expressing and localizing pain accurately, which complicates their clinical management. These conditions increase the risk of cardiopulmonary complications and airway management challenges during anesthetic procedures.

The combination of regional anesthesia and sedation offers a safe alternative for surgical procedures. However, it is essential to consider the risks associated with regional techniques. In particular, the interscalene block may cause hemidiaphragmatic paralysis and should be used cautiously in patients with pre-existing pulmonary compromise. Additionally, intravenous sedation presents a significant challenge in these patients due to limited cooperation and potential sensory deficits.

Objective

To describe the anesthetic management using interscalene block and intravenous sedation in a patient with Down syndrome undergoing major orthopedic surgery.

Methodology

A 30-year-old male with a history of Down syndrome and grade I obesity presented with a left humeral fracture and was scheduled for open reduction and internal fixation. Regional anesthesia with ultrasound-guided interscalene block and intravenous sedation was selected. The anesthetic plan was explained to the patient, who showed a cooperative attitude. 

In the operating room, under standard monitoring, sedation was administered with midazolam (1.5 mg), fentanyl (50 mcg), and a continuous propofol infusion (30 mcg/kg/min). Spontaneous ventilation was maintained with supplemental oxygen at 3 L/min via nasal cannula. The skin was infiltrated with 2% lidocaine (1.5 ml), and the interscalene block was performed with 0.75% ropivacaine (20 ml) without incident.

During the intraoperative period, the patient remained in the right lateral decubitus position. After two hours, he began to show signs of discomfort. Increasing the propofol infusion led to airway obstruction, prompting discontinuation of propofol and initiation of dexmedetomidine (0.7–0.8 mcg/kg/h), which provided adequate sedation without recurrence of obstruction.

The total duration of anesthesia was 5 hours and 35 minutes, during which the patient maintained spontaneous ventilation and stable hemodynamics. The postoperative period was uneventful, with effective pain control achieved. The patient was discharged 48 hours later without complications.

Results

The use of interscalene block combined with intravenous sedation allowed for a safe and effective major surgical intervention in a patient with Down syndrome. The only complication observed was transient airway obstruction, which resolved after changing the sedative agent. No major adverse events occurred, and adequate analgesic control was maintained.

Conclusions

Anesthetic management in patients with Down syndrome presents unique challenges, particularly due to their anatomical and functional abnormalities. In appropriately selected patients, regional anesthesia combined with intravenous sedation can be a safe and effective strategy, minimizing respiratory and cardiovascular risks associated with general anesthesia.