Effective Combined Spinal Epidural (CSE) Anaesthetic Technique for a High Risk Trauma Patient - A Case Report
- 1. Independent Consultant in U.K., currently @ Q.A.H., Portsmouth University Hospitals, UK
KEYWORDS
- General anaesthesia
- Ventilator
- Chronic obstructive lung disease
CITATION
Elrazek EA (2022) Effective Combined Spinal Epidural (CSE) Anaesthetic Technique for a High Risk Trauma Patient - A Case Report. Int J Clin Anesthesiol 10(1): 1118.
INTRODUCTION
The choice between General and regional anaesthesia has been always controversial. However, the decision always depends on the patient’s clinical condition [1]. In patients suffer from severe chronic obstructive lung disease (COPD), regional anaesthesia proved to be safer than general anaesthesia preoperatively, especially when it keeps the patient awake and in full control of his/her breathing [2]. Avoiding general anaesthesia and mechanical ventilation found to be advantageous in such patients because they could be ventilator dependent once they are ventilated mechanically [3]. Needless to say that putting patients with compromised respiratory functions on a mechanical ventilator could facilitate ventilator acquired pneumonia which could be fatal for those patients [4]. In emergency circumstances, where the anaesthetist has no enough time to optimise the patient’s clinical condition, regional anaesthesia could be safer than general anaesthesia especially in elderly patients [5]. Patients with compromised heart function including severe heart failure and multiple valve disease could also have the benefit of safe and careful regional anaesthesia [6]. Regional anaesthesia also known to be better for diabetic patients giving them the advantage of going back quickly to their own anti diabetic regime once they are able to eat and drink postoperatively [7].
We report a case of a revision total hip replacement in a high risk trauma patient with multiple co-morbidities including; obesity, diabetes, and severe cardio- pulmonary disease. The major operation was performed effectively using Combined spinal epidural anaesthesia (CSE) under sedation as a sole technique. This had significantly contributed to the complication free recovery experienced by the patient, which helped him to be discharged home safely and quickly.
THE PATIENT’S CLINICAL BACK- GROUND
At pre-anaesthetic assessment prior to surgery , the patient’s found to be 73 years old man with BMI of 40 and he was a heavy smoker (15-20 / day / years). He had chronic productive cough due to long standing history of COPD and was on four different inhalers; Bricanyl, Spiriva and Symbicort regularly plus Salbutamol when needed. Although his pre-operative chest X-Ray was reported to be clear, his chest sounded generally wheezy with reduced air entry bilaterally. The patient’s bed side peak expiratory flow rate [PEFR] was 250 L/m. His latest Pulmonary function tests were borderline, where his peak expiratory volume in one second [FEV1] was 1.5 litres [54% predicted], and his FEV1/FVC ratio (FVC: Forced vital capacity) was 45% pre and post bronchodilator. His six minutes walk test [6MWT] detected an overall low level at 223 meters [predicted distance in healthy elderly = 631 +/- 93 meters] [8], and he was diagnosed to have moderately severe irreversible COPD?
His recent ECG showed signs of IHD with left axis deviation and his ECHO detected EF of only 30% and he was dependant on regular Digoxin 125 mg O.D. and Furosemide 40 mg BD. He has a history of high blood pressure on Ramipril 10 mg OD and Amlodipine 5 mg O.D., and type 2 DM on Glucophage as 500 mg tid.
His exercise tolerance was very limited due to his compromised cardio respiratory status and his advanced osteoarthritis (O.A.), where he was able to walk few yards only with a walking aid and can’t manage the stairs.
Anaesthetic technique
- Preoperatively, the patient was assessed and all anaesthetic problems were determined.
- In theatre, the patient was checked in according to the WHO protocol, a reliable I.V. X 2 accesses were established, all non invasive monitors were applied and an arterial line was secured. Later, an U.S. guided Fascia Iliaca block (30 ml of Leavobupivacaine 0.25%) was done helping the patient to lie on the sore side facilitating the two separate injections CSE anaesthetic technique (1.5 ml of Heavy Bupivacaine 0.5 with 25 ug Fentanyl for the spinal + an epidural infusion of Bupivacaine 0.1% / Fentanyl 2ug per ml started @ 10 ml/h). The anaesthetic technique and the surgery was performed under Propofol TCI sedation all the way through.
- After 5 hours of difficult surgery using the cell saver, the sedation was stopped and the patient was transferred to the recovery room for observation and stabilisation. Later, he was moved to the ward in a very stable clinical condition where he stayed for two days before he was able to go home safely.
DISCUSSION
It is well known that giving general anaesthetics to high risk patients with significant pulmonary disease can trigger some adverse side effects including; laryngospasm, bronchospasm, atelectasis, lung collapse, pneumonia, barotrauma, and biotrauma, and subsequently intra and post-operative hypoxaemia. Impaired cardiac performance, neuromuscular, and psychological complications are also possible [2,3]. Regional anaesthesia including; spinal, continuous spinal, combined spinal epidural (CSE), or epidural anaesthesia with or without sedation remain to be other safer options than general anaesthesia for Lower limbs (L.L.) trauma patients. In L.L. orthopaedic trauma operations, spinal anaesthesia is simple, but finite and might not be enough for long operations [9]. Continuous spinal anaesthesia is more invasive procedure with significant incidence of post operative headache [9]. Epidural anaesthesia can cover a long period surgery, however its slow induction time might be a disadvantage specially in an emergency situation [9, 10]. CSE, found to be more practical, flexible and safe anaesthetic regional technique, allowing better haemodynamic stability, quicker surgical start with profound muscle paralysis for long time surgery as well as an excellent postoperative analgesia and effective physiotherapy [10-13]. However, a special attention should be given avoiding the possible upward migration of the epidural blockade by constant monitoring for the upper level of the block postoperatively [14].
In addition to the above mentioned advantages, CSE regional anaesthetic technique found to have more general physiological benefits facilitating better and quicker recovery including; A: Blunting the decrease of the subcutaneous tissue oxygen tension caused by surgical stress and the adrenergic vasoconstriction that likely to happen during major orthopaedic trauma surgery providing sufficient tissue oxygenation, and improving cardiac, respiratory, renal, and gastrointestinal function and may decrease the incidence of post operative surgical wound infection, B: Blocking the upper lumbar (L1&L2) splanchnic sympathetic nervous supply will result in reduced inhibitory gastrointestinal tone, increased intestinal blood flow, and the return of the normal function of the gastrointestinal tract of these patients, C: Controlling the patients post operative pain can significantly decrease the incidence of post operative morbidity and mortality secondary to pulmonary complications, these patients can breath spontaneously better, cough effectively, and subsequently clear third chest better, D: Lowering the incidence of post operative myocardial infractions in comparison to same type of patients received general anaesthesia for similar surgery, E: Reducing the pathophysiological response to surgical trauma including; pain, nausea, vomiting, ileum, stress-induced catabolism, impaired pulmonary function, increased cardiac demand, and risk of thromboembolism [14-16].
Needless to say, that all the above-mentioned complications -if they happen - will require more treatment and delay the patient’s recovery and discharge from hospital causing more burden on the NHS [17].
Reviewing the literature and based on the positive outcome of the case that we have reported, we believe that regional anaesthetic techniques especially CSE can allow excellent quality of surgery and enhanced recovery especially for compromised trauma patients having major long time L.L. orthopaedic surgery. We believe that the anaesthetist has a pivotal role in surgery facilitating early post - operative recovery, providing a minimally invasive anaesthesia and analgesia and may be tailoring his anaesthetic strategy to meet the surgical as well as the patient’s demand in view of type of surgery and the pathophysiological condition of that patient.
Adding to the significant positive outcome of the suggested regional anaesthetic technique offers, we learn from the current COVID-19 pandemic that regional anaesthesia has been strongly recommended because it could be safer to the anaesthetic staff decreasing their contact with the patient’s airway. Also, regional anaesthesia could decrease the burden on the NHS by speeding up the rate of the patient’s discharge from hospitals aiming at decreasing the incidence of nosocomial infection because of long hospitalisation, decreasing the cost of treatment, and allowing more beds for other patients shortening their waiting operative lists [18].
Finally, we strongly recommend to continue encouraging the suggested CSE technique for high risk surgical co-morbid orthopaedic trauma patients having major long time lower limbs operations.
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