thorasic epidural anesthesia (case report)

CASE REPORT

Thoracic epidural anesthesia
For
exploration of hydronephrotic kidney
Dr.Wasfi A.K.Ali MB.ChB D.A
Chief of anesth. Dept.Tikrit Teach.Hosp.
Nov.2000
ABSTRACT
A 65 YEARS OLD MAN SUFFERED FROM CHRONIC HEMATURIA, CYSTOSCOPY DONE FOR HIM UNDER LUMBER EPIDURAL ANESTHESIA. DISCOVERED TO HAVE BIG BLADDER TUMOR OBSTRUCTING BOTH URETERIC ORIFICES, THIS NECESSATED OTHER SURGERY TO RELEIF THE DISTAL OBSTRUCTION AND DECREASE THE HIGH BLOOD UREA .DUE TO THE SHORTAGE OF GENERAL ANESTHETIC DRUGS AND SHORTAGE OF INVESTIGATIONS , DUE TO THE EMBARGO AND DUE TO THE RISK OF SPINAL ANESTH. IN KID. POSITION SO THORACIC EPIDURAL ANESTH.DONE FOR HIM AS THE ONLY AVAILABLE METHOD .SUCCESSFULE ANESTH. DONE CHOOSING THE T10,11 VERTEBRAL INTERSPACE,NEPHROSTOMY DONE AND PLEASANT POST OP. RECOVERY
INTRODUCTION
Lumber epid.anesth.was used in tikrit teaching hosp.since 1993 , but thoracic epid . anesth.was used in limited occasions before for highly selected cases whom are unfit for other types of G.A.or regional anesth. As for exploration of common bile duct with CA head of pancreas that was during an episode of strong shortage of general anesth. agents .Now due to other shortage of general anesth. drugs we used Thoracic Epidural Anesthesia (T.E.A.)for a 65 years old man with chronic renal failure , of B urea 100 mg /100ml after repeated dialysis , serum k+ not available ,Hb 11gm /100ml Cystoscopy done for him under lumber epid . anesth. Then after diagnosis of the cause which was abig bladder tumor obstructing both ureteric orificies, this made urgent exploration and nephrostomy is mandatory to relief the distal obstruction .T.E.A was the only available method of anesth. which was done successfuly
Methods
*In TEA we introduced the epid . needle (touhy)in the epid.space at the thoracic level T7-T8 after raising a wheel ,this level was calcified so we choosed lower level T10-T11 , by loss of resistance technique epid .space was identified ,one shot dose of 12cc lignocaine 2% with adrenaline 1/100000, the position of the patient is sitting during injection .after injection we put the patient in the usual kidney modified lateral position with hyper extended ends for a flank incision.After the injection of lignocaine parasthesia and intense anesthesia started ,sedation was given (midazolam) 2.5mg and 100% O2 by mask, ECG monitoring
ResultsIntense anesthesia was elicited by pin prick of the flank ,while there is still movement of the legs ,hypotension occurred but was related mainly to the lateral position where the kid. bridge exerts pressure on the inferior vena cava, although i.v. fluids was given and B.P was improved significantly after the return to the supine position , the B.P was 100/60 on supine position .Nephrostomy done within 1.5hr. ,the patient was discharged well to the general ward with elevation of the legs and observation of the B.P
Discussion
regarding the epid.and spinal anesth.,there is shortage in nearly all the safe vasoconstrictors since 1993 in ower center, the only vasoconstrictor available is adrenaline which is given diluted i.v. causciously in case of sever hypotension ,though it is not the standared tech. to treat hypot.
*using spinal anesth .in lateral position with hyperextension of the ends of the table may carry the risk of high spinal anesth. with great complications
*general anesth.was not given because we have no safe muscle relaxant for uremics as atracuriurm,the antidote also was not available ,suxamethonium chloride (scoline ) was not used intermittently because we should have normal serum k+ which was not available in the labs.
Conclusion
*the shortage of anesth.drugs due to embargo changed allot the anesth. techniques and increased the experience in fields not used before in iraq as a routine ,TEA and lumberE.A. are examples of anesthesia when there is shortage of drugs or the patient wants regional technique or he refuse G.A.
References
1-Thoracic epidural infusion of bupivacain of the upper abdominal surgery ,Brendua T.MBB Ch.BAO et al. American J. of Anesthesia 1999
2-T.EA. Klaus kirno M.D.Ph.D. et al .Sweden Anesth.Analgesia1994
3-Sequential combined spinal.epid. block ,versus spinal block ,T.H. Thoren M.D. et al. Sweden .Anesth. Analgesia 1994
4- Extension of epid. Block for emergency caesarian section M.A.S. Dickson FFARCSI ,Ediaburgh Anesthesia 1994
5-Comparison of four narcotic analgesics for extra dural analgesia. T.A.Torado and D.A.pybus Australia ,Brit.J. of anaesthesia 1982.
6- Effects of extra dural analgesia to upper abdominal surgery . C. Traynor,J.I. Paterson Brit.J. of anaesth.1982
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