An 80-year-old patient with critical aortic stenosis, DNR, walking on a thin line, in and out of congestive heart failure presents for free-flap surgery of the ipsilateral forearm due to an open wound over the elbow, with a skin graft from the anterolateral thigh. Here’s how we used regional anesthesia to ensure the safest outcome for the patient.

Anesthesia consisted of

• Costoclavicular brachial plexus block with 15 mL of 0.5% ropivacaine, followed by an infusion through the catheter for better perfusion-longevity of the graft postoperatively.
• Lateral femoral cutaneous nerve and femoral nerve blocks, with 5 mL of 0.25% bupivacaine for each nerve, for anesthesia of the skin graft. 

The surgery proceeded uneventfully and was successful. No other anesthetic agents were administered.

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