Segmental spinal anaesthesia for cholecystectomy in a patient with severe lung disease
1Department of Anesthesiology, ICU and Pain Therapy, Catharina Hospital—Brabant Medical School Michelangelolaan 2, NL-5623 EJ Eindhoven, The Netherlands
2Department of Surgery, Catharina Hospital—Brabant Medical School Michelangelolaan 2, NL-5623 EJ Eindhoven, The Netherlands
3Department of Pulmonology, Catharina Hospital—Brabant Medical School Michelangelolaan 2, NL-5623 EJ Eindhoven, The Netherlands
4Department of Anaesthesia, Ninewills Hospital & Medical School Dundee DD1 9SY, UK
*Corresponding author. E-mail: zundert{at}iae.nl
Accepted for publication January 23, 2006.
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Abstract |
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Occasionally patients awaiting heart or lung transplant because of terminal disease require other types of surgery, but present significant challenges to the anaesthetist because of impaired organ function. Regional anaesthesia may have much to offer such patients and we here report one who underwent successfully a laparoscopic cholecystectomy under segmental subarachnoid (spinal) anaesthesia performed at the low thoracic level. The anatomical and physiological consequences of such a technique are discussed.
Keywords: anaesthetic techniques, regional, spinal; surgery, laparoscopic cholecystectomy
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Case report |
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The patient (male, 47 yr, 78 kg, 181 cm), who had been a heavy smoker until 10 yr previously, had chronic obstructive pulmonary disease with severe emphysema attributable to homozygote
-1-antitrypsine deficiency type ZZ. He suffered from frequent respiratory infections, required continuous oxygen therapy and had severe functional impairment, even minimal activity (e.g. washing himself, eating a meal) producing significant dyspnoea. Arterial (radial sample) blood gas analysis (oxygen therapy 1 litre min–1 via nasal catheter) showed moderate hypoxaemia at rest, with the limited activity, which the patient was capable of exaggerating and producing a respiratory acidosis as well (Table 1). Pulmonary function tests showed a severely obstructive pattern (Table 2). Lung transplantation was agreed to be the appropriate management, but gallstones were discovered during assessment and cholecystectomy was considered a necessary preliminary procedure to avoid the possibility of acute cholecystitis and associated infection complicating the postoperative period. However, the patient's respiratory state raised considerable anaesthetic concerns and surgery was denied at two other major institutions before he was referred to us.
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After considering the options, and discussing them with both patient and surgeon, a decision was taken to use a combined needle through needle spinal/epidural anaesthetic (CSEcureTM, SIMS Portex, Hythe, Kent, UK). No premedication was given and the block was performed at the 10th thoracic interspace. With the patient in the left lateral recumbent position, the epidural (16 swg Tuohy) and spinal needles (27 swg pencil point type) were inserted without discomfort and a free flow of CSF obtained before 1.0 ml plain bupivacaine 0.5% plus sufentanil 2.5 µg (0.5 ml) was injected. The epidural catheter (19 swg) was then inserted and taped to the back of the patient who was then placed supine. Within 3 min a segmental sensory (pinprick) block, extending between the third thoracic and second lumbar dermatomes, was obtained, but without any motor weakness in the legs or hint of respiratory distress. The distribution of block remained static at 10 min, but blood pressure decreased from 122/84 to 82/67 mm Hg, and heart rate from 80 to 56 beats min–1, although there was no nausea or vomiting. The hypotension responded well to i.v. ephedrine 10 mg and cholecystectomy, using a laparoscopic technique, was started. The circulation remained stable during the operation (during which 1600 ml of i.v. crystalloid fluid was given) and into the postoperative period.
The patient received oxygen 4 litre min–1 via nasal catheters (
>97% during the operation and throughout the recovery period. Surgery (duration 43 min; intra-abdominal pressure limited to 10 cm H2O) was performed easily and uneventfully, causing no respiratory or other difficulty to the patient who followed the whole operation on a video monitor. No sedative or additional analgesic drugs were given, but a continuous epidural infusion of bupivacaine 1.25 mg ml–1 with sufentanil 1 µg ml–1 was started at 5 ml h–1 at the end of the operation, and continued for 2 days. The same extent of sensory block, still without lower limb weakness, was present at the end of the operation as at the beginning, and the patient was able to move himself unaided back from the operating table to his bed. Postoperative recovery was uneventful (specifically there were no neurological sequelae), and there was no further deterioration in pulmonary function tests (Table 2), allowing the patient to be discharged from hospital on Day 4. The patient is still waiting for an appropriate lung transplant.
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Discussion |
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This report shows that the combined spinal/epidural anaesthesia technique, applied in the lower thoracic region and with a minute dose of local anaesthetic, can be used to provide a segmental subarachnoid block sufficient to allow laparoscopic cholecystectomy to be performed, even in a patient with severely abnormal respiratory function. To our knowledge this is the first account of this technique for such surgery, but such an anaesthetic approach will raise two major concerns.
The first anxiety is that puncturing the dura mater in the thoracic region can lead to needle damage to the spinal cord, avoidance of this risk being the main reason why spinal anaesthesia is traditionally performed at the lumbar level. This anxiety has been increased by a report that the accidental performance of spinal anaesthesia at a higher level than the intended one of L2–L3 can result in spinal cord damage.1 However, consultation with radiological and neurological colleagues revealed that spinal puncture at the cervical and thoracic levels was regular practice for myelography when that investigation was used more widely. Measuring the space between the dura mater and the mid to lower thoracic spinal cord on MRI scans showed that its width is actually greater than that of the epidural space at that level because the thoracic spinal cord lies anteriorly in the theca (A. van Zundert and J. Wontergem, unpublished observations, Fig. 1). Thus cautious use of intrathecal injection in the thoracic segments may be as much an option as epidural block for the experienced clinician. The lumbar spinal cord is situated more dorsally and takes up more space because of the lumbar enlargement so that it is at greater risk of needle damage as shown by Reynolds's reports of pain and paraesthesiae when needles were inserted at that level.1
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The second anxiety is that the extensive thoracic nerve block produced might result in ventilatory impairment. The main inspiratory muscle, the diaphragm, will be unaffected because it is innervated from the cervical level, and expiration is normally a passive phenomenon at rest. However, forceful expiration and coughing will be affected because they are generated primarily by the muscles of the anterior abdominal wall which are innervated by the thoracic nerves.2 3 The use of very low doses of local anaesthetic should minimize the degree of nerve block, and thus muscle weakness, but the technique could have disastrous effects in an individual patient with a pattern of obstructive airways disease dependent on active expiration to maintain lung ventilation. The pressure of the pneumoperitoneum also needs to be controlled carefully during surgery to ensure adequate diaphragmatic excursion.
Clearly, patients receiving this technique must be assessed very carefully and managed by anaesthetists with considerable experience of regional anaesthesia. It may be argued that this particular patient could have been managed using other anaesthetic techniques, particularly general anaesthesia with artificial ventilation, but this ignores the refusal of two separate groups of experienced clinicians to use that, or any other, anaesthetic approach. A number of other regional techniques (catheter spinal, thoracic epidural, paravertebral or infiltration with coeliac plexus block) were also possible. However, a combined spinal/epidural was chosen because of personal familiarity with a highly reliable technique which can provide profound block (so minimizing the need for sedation) for surgery and good quality analgesia thereafter without the need for large doses of any drug. We did not feel that the other options provided the right balance of such features although we recognize that others, with different expertise, might have chosen otherwise. There is never a ‘right’ way to anaesthetize such a patient, but what is described here is an option to expand the boundaries of regional anaesthesia by performing spinal anaesthesia (or, in this case, combined spinal/epidural anaesthesia/analgesia) in a new way which may be to the advantage of certain patients. Since this operation the technique has been used in another 30 patients (without respiratory problems) with excellent results and no untoward effects.
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Acknowledgments |
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We would like to thank the patient for his permission to publish details of his case. Financial sources: this study was supported solely by departmental resources.
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References |
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1 Reynolds F. Damage to the conus medullaris following spinal anaesthesia. Anaesthesia 2001; 56:238–47[CrossRef][Web of Science][Medline]
2 In Standring S (Ed.). Gray's Anatomy 2005; 39th edn Edinburgh Elsevier pp. 1084–6
3 Freund FG, Bonica JJ, Ward RJ, Akamatsu TJ, Kennedy WF. Ventilatory reserve and level of motor block during high spinal and epidural anesthesia. Anesthesiology 1967; 28:834–7[CrossRef][Web of Science][Medline]
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