Propofol and Ketamine for Targeted Muscle Reinnervation after Limb Amputation: A Case Report

  • Angela Hupman, SRNA Student Registered Nurse Anesthetist Georgetown University
  • Ladan Eshkevari, PhD, CRNA Assistant Director & Professor Georgetown University Nurse Anesthesia Program


Surgical procedures that require neuromuscular monitoring

present unique challenges to the anesthesia provider. Specific

patient characteristics such as phantom limb pain or chronic

opioid use can further complicate perioperative management. The

following case presentation illustrates the anesthetic management

of a patient exhibiting these complications who presented for

surgery with a prior transhumeral amputation. Nerve reassignment

was planned with the eventual goal of a thought-controlled

prosthesis. Anesthesia was maintained by the combination of

propofol and ketamine along with adjuncts such as hydromorphone,

midazolam and glycopyrrolate. These drugs and similar

anesthetic combinations cause minimal changes to neurophysiologic

monitoring while decreasing various types of neuropathic

pain and provide an effective alternative for treating patients with

chronic pain.


1 Kuiken TA, Li G, Lock BA, et al. Targeted muscle reinnervation
for real-time myoelectric control of multifunction
artificial arms. JAMA. 2009;301(6):619-628.
doi: 10.1001/jama.2009.116.
2 Seubert CN, Mahla ME. Neurologic monitoring. In:
Miller R, ed. Miller’s Anesthesia. 7th ed. Philadelphia, PA:
Churchill Livingstone; 2010:1477-1541.
3 Wang AC, Than KD, Etame AB, La Marca F, Park P.
Impact of anesthesia on transcranial electric motor evoked
potential monitoring during spine surgery: a review
of the literature. Neurorsurg Focus. 2009;27(4):1-4.
4 Alviar MJ, Hale T, Dungca M. Pharmacologic interventions
for treating phantom limb pain. 2011. The Cochrane
551858.CD006380.pub2/full. Accessed January 28, 2012.
5 Sigtermans MJ, van Hilten JJ, Bauer MCR, et al. Ketamine
produces effective and long-term pain relief in patients
with complex regional pain syndrome type 1. Pain.
2009;145(3):304-311. PMID:19604642.
6 Loftus RW, Yeager MP, Clark JA, et al. Intraoperative
ketamine reduces perioperative opiate consumption in
opiate-dependent patients with chronic back pain
undergoing back surgery. Anesthesiology. 2010;113(3):639-
646. PMID: 20693876.
7 Dao J. Learning to accept, and master, a $10,000
mechanical arm. The New York Times. November 27,
How to Cite
HUPMAN, SRNA, Angela; ESHKEVARI, PHD, CRNA, Ladan. Propofol and Ketamine for Targeted Muscle Reinnervation after Limb Amputation: A Case Report. Anesthesia eJournal, [S.l.], v. 1, n. 1, jan. 2013. ISSN 2333-2611. Available at: <>. Date accessed: 24 feb. 2020.


propofol, ketamine, TIVA, targeted muscle reinnervation, phantom limb pain