Stellate Ganglion Block for the Management of Long COVID Symptoms

Mina G, Dhoon T Q, Rahimian R, et al.

Cureus 17(7): e88686. doi:10.7759/cureus.88686

Photodynamic bone stabilization (PBSS) is a minimally invasive option often used in patients with metastatic bone disease who are poor surgical candidates. This case report presents a fatal cardiopulmonary collapse following balloon insufflation during PBSS in a 68-year-old woman with advanced sarcoma and pulmonary hypertension. After uneventful induction and reaming of the right humerus, the patient experienced pulseless electrical activity and severe hypoxia immediately following balloon inflation. Transesophageal echocardiography showed severe right heart strain, and extracorporeal membrane oxygenation was initiated. Despite supportive measures, the patient died five days postoperatively.

The authors attribute the embolic event to debris from intramedullary reaming, which was likely forced into systemic circulation during balloon insufflation. Risk factors in this patient included pulmonary hypertension, right ventricular dysfunction, metastatic lung disease, and advanced age. The authors emphasize that even anatomic sites considered low risk, like the humerus and ilium, can lead to fatal complications in vulnerable patients.

They recommend preoperative echocardiography, bubble studies to rule out intracardiac shunting, intraoperative TEE, and early arterial access for high-risk individuals. Surgical technique modifications—such as canal suctioning, distal vent creation, and slow monomer infusion—may mitigate the embolic load. Effective communication between the surgical and anesthesia teams and readiness for ECMO are also advised.

References

1. IlluminOss Medical. Surgical Technical Guide: Humerus, radius and ulna. (2019). Accessed: August 29, 2024: https://illuminoss.com/uploads/nuggets/5eaa859f7ee3385fc186902b/2019-All-forearm-surgical-technique-.pdf.

2. Zoccali C, Attala D, Pugliese M, et al. BMC Musculoskelet Disord. 2021, 22:63. doi:10.1186/s12891-020-03927-6

3. Sabharwal S, Boland PJ, Vaynrub M. JBJS Case Connect. 2024, 14:e23.00634. doi:10.2106/JBJS.CC.23.00634

4. Zyskowski M, Wurm M, Greve F, et al. J Clin Med. 2022, 11:7178. doi:10.3390/jcm11237178

5. Gausepohl T, Pennig D, Heck S, et al. Orthop Rev (Pavia). 2017, 9:6988. doi:10.4081/or.2017.6988

6. Arcelus JI, Kudrna JC, Caprini JA. Orthopedics. 2006, 29:506-16. doi:10.3928/01477447-20060601-16

7. Bone cement implantation syndrome. Anaesthesia Tutorial of the Week (2024). Accessed: August 29, 2024: https://resources.wfsahq.org/atotw/bone-cement-implantation-syndrome.

8. Lempert M, Halvachizadeh S, Ellanti P, et al. J Clin Med. 2021, 10:2733. doi:10.3390/jcm10122733

9. Pitto RP, Koessler M, Kuehle JW. J Bone Joint Surg Am. 1999, 81:831-43. doi:10.2106/00004623-199906000-00010

10. Koval KJ, Zuckerman JD. J Orthop Trauma. 2009, 23:386-94. doi:10.1097/BOT.0b013e3181761502

11. Hoxie SC, Sperling JW, Cofield RH. J Shoulder Elbow Surg. 2007, 16:782-3. doi:10.1016/j.jse.2006.12.004

12. Longo DL. Blood. 2008, 112:sci-1. doi:10.1182/blood.V112.11.sci-1.sci-1

13. Dharma S, Kedev S, Jukema JW. Heart. 2013, 99:279-84. doi:10.1136/heartjnl-2012-302577

14. Kindler CH, Evgenov OV, Crawford LC, et al. Miller’s Anesthesia. Gropper MA, Cohen NH, Eriksson LI, et al. (ed): Elsevier; 2019.

15. Hope WW, Demeter BL, Newcomb WL, et al. Am J Surg. 2007, 194:814-8. doi:10.1016/j.amjsurg.2007.08.036

16. Davies MG, Hart JP. Front Cardiovasc Med. 2023, 10:1298686. doi:10.3389/fcvm.2023.1298686

17. Klein AA, Skubas NJ, Ender J. Curr Opin Anaesthesiol. 2014, 27:111-9.

18. Maitre S. Virtual Mentor. 2006, 8:590-2. doi:10.1001/virtualmentor.2006.8.9.cprl1-0609

19. Deng T, Xu K, Wu B, et al. BMC Pulm Med. 2022, 22:225. doi:10.1186/s12890-022-02016-9

Thank you to Cureus for publishing this case and supporting the open sharing of clinical experiences that contribute to improved anesthesia and surgical outcomes.