Total Intravenous Anaesthesia with Propofol and Remifentanil for Brachial Plexus Repair in the Prone Position: Insights from a Case Series

Dear Editor, Brachial plexus injuries, most commonly resulting from high-velocity road traffic accidents, predominantly affect young adults and are frequently associated with severe functional impairment. Primary nerve root avulsion has been reported in up to 70%–80% of cases, necessitating early surgical intervention for optimal recovery.[1] Among the various surgical strategies, nerve transfers such as spinal accessory to supra-scapular nerve transfer are commonly performed to restore shoulder abduction and stability. These procedures are typically undertaken in the prone position using a posterior supra-clavicular approach, which offers improved surgical access to the target nerves.[1,2] A critical component of these procedures is the intra-operative identification of functional nerve elements using direct peripheral nerve stimulation. This requirement necessitates avoidance of neuromuscular blocking agents, as they suppress muscle responses and hinder accurate nerve localisation. Consequently, the anaesthetic management of such cases becomes particularly challenging, requiring a careful balance between adequate depth of anaesthesia, immobility and preservation of neuromuscular transmission. We report a series of three cases of brachial plexus repair performed under total intravenous anaesthesia (TIVA) using propofol and remifentanil, with avoidance of neuromuscular blockade after induction. This series highlights the feasibility and effectiveness of this technique, particularly in the prone position and in resource-variable settings where advanced monitoring tools may not always be available. All patients were classified as American Society of Anesthesiologists physical status I and underwent a comprehensive pre-operative evaluation. Standard intra-operative monitoring included electrocardiography, non-invasive blood pressure, pulse oximetry, end-tidal carbon dioxide and temperature. Anaesthesia was induced with intravenous propofol and remifentanil. Neuromuscular blockers were intentionally avoided, except in the first case, where succinylcholine was administered to facilitate endotracheal intubation. Following induction, patients were mechanically ventilated with an oxygen–air mixture (FiO2 0.5) and subsequently positioned prone with meticulous attention to padding and pressure point protection. A multi-modal analgesic regimen was employed in all cases, consisting of intravenous paracetamol and diclofenac, with cautious use of tramadol when required. Prophylactic ondansetron was administered to reduce the incidence of post-operative nausea and vomiting. In the first case, due to the unavailability of a target-controlled infusion (TCI) pump, manually controlled syringe pumps were used. Remifentanil was administered as a bolus (2 μg/kg) followed by infusion titrated between 0.05 and 0.2 μg/kg/min, while propofol was maintained at 100 μg/kg/min. Succinylcholine (2 mg/kg) was used solely to facilitate intubation. Haemodynamic parameters remained stable throughout the procedure, and no intra-operative movement was observed. In the second case, a TCI pump utilising the Minto pharmacokinetic model was employed for remifentanil administration, with an effect-site concentration maintained at 4.0 ng/mL.[3] Propofol infusion was continued at 100 μg/kg/min using a syringe pump. Endotracheal intubation was successfully achieved without the use of muscle relaxants, and intra-operative conditions remained optimal. In the third case, both propofol and remifentanil were administered using a TCI-based approach. Propofol was delivered using the Schnider model, initiated at an effect-site concentration of 5 μg/mL and subsequently reduced to 2.5 μg/mL following intubation. Remifentanil infusion was maintained at 0.2 μg/kg/min. Intubation was accomplished without neuromuscular blockade, and the patient remained haemodynamically stable throughout the procedure. In all three cases, the combination of propofol and remifentanil provided adequate anaesthetic depth, excellent operating conditions and complete suppression of patient movement despite the absence of neuromuscular blockade. Following cessation of infusions, patients were repositioned supine and extubated within 7–15 min. Recovery was smooth and uneventful, with all patients achieving a modified Aldrete score >9 before transfer to the ward. The prone position introduces additional anaesthetic considerations, including limited access to the airway, risk of pressure-related injuries and challenges in monitoring. Maintaining an adequate depth of anaesthesia is essential to prevent complications such as haemodynamic instability, ventilator asynchrony and involuntary motor responses, which could compromise both patient safety and surgical precision. In the absence of processed electroencephalographic monitoring such as bispectral index, TIVA in the prone position presents challenges, including limited airway access and the need for vigilant monitoring. Remifentanil is particularly well-suited for such scenarios due to its unique pharmacokinetic profile. It undergoes rapid metabolism by non-specific plasma and tissue esterases, resulting in an ultra-short context-sensitive half-time of approximately 3 min, independent of infusion duration.[4] This allows for precise titration, rapid adjustments in anaesthetic depth and prompt recovery following discontinuation. When combined with propofol, remifentanil provides synergistic effects that enhance hypnosis and analgesia while attenuating haemodynamic responses to noxious stimuli such as laryngoscopy and surgical manipulation. Previous studies have demonstrated that this combination enables tracheal intubation without neuromuscular blockade and reduces the overall requirement for hypnotic agents.[5] These properties make it particularly advantageous in surgeries requiring intra-operative neuromonitoring. However, remifentanil is not without limitations. Its rapid offset of action results in minimal residual analgesia, necessitating the use of adjunctive analgesics to ensure adequate post-operative pain control. Furthermore, high-dose or prolonged infusions have been associated with opioid-induced hyperalgesia, which may increase post-operative analgesic requirements.[5] These considerations underscore the importance of adopting a multi-modal analgesic strategy. In conclusion, our case series demonstrates that TIVA using propofol and remifentanil without neuromuscular blockade is a safe and effective anaesthetic technique for brachial plexus repair in the prone position. It facilitates optimal surgical conditions, preserves neuromuscular function for intra-operative nerve identification and ensures rapid and smooth recovery. This approach is particularly valuable in settings where resources may be limited. Further prospective studies with larger sample sizes are warranted to validate these findings and establish the standardised protocols. Authors’ contributions KSR helped in in concept design, intellectual content, literature search, manuscript preparation, manuscript editing and manuscript review. PD helped in concept design, intellectual content literature search, manuscript preparation, manuscript editing and manuscript review. She is being designated as corresponding author of the article. RRP helped in manuscript editing and manuscript review. VG helped in manuscript editing and manuscript review. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.