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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 3  |  Page : 324-327 Table of Contents     

Continuous Spinal Anaesthesia an Underused Technique Revisited: A Case Report


1 Assistant Professor, Department of Anaesthesiology and Intensive Care, St. John's Medical College Hospital, Bangalore-560034, Karnataka, India
2 Professor, Department of Anaesthesiology and Intensive Care, St. John's Medical College Hospital, Bangalore-560034, Karnataka, India
3 Professor & Head, Department of Anaesthesiology and Intensive Care, St. John's Medical College Hospital, Bangalore-560034, Karnataka, India

Date of Acceptance03-Apr-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Reena Nayar
Department of Anaesthesiology and Intensive Care, St. John's Medical College Hospital, Bangalore-560034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


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A 35-year-old male patient with ischaemia of the right lower limb due to peripheral vascular disease, with comorbid conditions such as coronary artery disease, hypertension and COPD, was posted for a femoro femoral crossover graft. A continuous spinal anaesthesia technique was used, wherein bolus doses of bupivacaine 0 .5% was delivered intermittently in the subarachnoid space, via a 20 gauge epidural catheter. The benefits of this technique were the rapidity of action, minimal of the amount of drug used., and an ability to achieve the desired segmental level of anaesthesia. A review of literature, analysis of benefits and drawbacks of this underused technique is presented.

Keywords: Continuous spinal anaesthesia, Intermittent bolus, Vascular surgery lower limb


How to cite this article:
Nayar R, Satyanarayana P S, Sahajanand. Continuous Spinal Anaesthesia an Underused Technique Revisited: A Case Report. Indian J Anaesth 2008;52:324-7

How to cite this URL:
Nayar R, Satyanarayana P S, Sahajanand. Continuous Spinal Anaesthesia an Underused Technique Revisited: A Case Report. Indian J Anaesth [serial online] 2008 [cited 2019 Sep 20];52:324-7. Available from: http://www.ijaweb.org/text.asp?2008/52/3/324/60643


   Introduction Top


The perioperative management of vascular sur­gery is challenging due to the presence of co existing diseases in the patient. Anaesthesia techniques are con­troversial, as vascular procedures lend themselves to local, regional, general or combined regional, and gen­eral anaesthesia [1] .

Continuous epidural anaesthesia (CEA) is gener­ally accepted as the routine method of regional anaes­thesia for vascular surgery of the lower limb. However continuous spinal anaesthesia (CSA ) has been reported to be more rapid in action, producing more pronounced sensorimotor blockage , with fewer haemodynamic alterations and side effects, when used for lower limb surgery than CEA , and single dose spinal anaesthesia (SDSA) [2],[3] .

We report the use of continuous spinal anaesthe­sia in a young male with multiple comorbid conditions, undergoing vascular surgery of the lower limb.


   Case report Top


A 35-year-old male, a chronic smoker presented to the Department of Surgery, St. John's Medical Col­lege Hospital in Bangalore, in February 2007, com­plaining of pain in the right lower limb for 3 months. He was a hypertensive, under control with medications, with a history of ischaemic heart disease . He was noted to have pulsations absent in the right femoral, popliteal and dorsalis pedis artery, and was diagnosed to have ischaemia of the right lower limb due to peripheral vas­cular disease.

His investigations revealed a raised haemoglobin percentage (19.1gms.dl -1 ) His electrocardiogram showed Q waves, with T inversion in Lead II, III and aVF , V5 and V6 and signs of left ventricular hypertro­phy .The chest X ray showed emphysematous lung fields with cardiomegaly .

His echo cardiography showed a perforated an­terior mitral leaflet, with mild mitral regurgitation and a dilated left ventricle (LV), a hypertrophied septum, mid basal posterior wall akinesia , reduced LV global func­tion, with a reduced ejection fraction (32%) The coro­nary angiography studies showed that the dominant right coronary artery had diffuse coronary artery disease upto the bifurcation .The abdominal aortography showed oc­clusion of the right common iliac artery.

After an initial period of stabilization he was posted for a cross over femoro femoral grafting, with a syn­thetic graft.

Under full aseptic precautions a 20 gauge Perifix ® epidural catheter via a 19 gauge Tuohy needle was inserted into L3-4 space . 0.5% bupivacaine was given via a bolus technique. The initial dose was 1.2 ml ( as 0.2 ml would be retained in the catheter), which re­sulted in a level of sensory block upto T 12, subse­quent infusion of 0 .5 ml raised the level of block upto T 10 . A further 3 bolus doses of 0.5ml bupivacaine each ,every 1 hour were necessary to maintain adequate sensory motor blockade during surgery . A final bolus dose contained 25 microgm fentanyl as an analgesic.

The surgery time was 210 minutes with a blood loss of 300 ml replaced with iv fluids .The patient was haemodynamically stable with a heart rate maintained between 62-70 minute. The blood pressure was main­tained between 130/ 80 to 150/100 with a mean of 140/90. The surgeon and the patient were comfort­able during the course of the procedure .The patient was covered with antibiotics preoperatively.

Post operatively the sensory blockade persisted for 3 hours following the end of surgery .The catheter was removed 6 hours after the noted time of intra op­erative heparin administration . The EKG showed no fresh changes at 0, 6 hrs and 24 hours. The Trop I values were normal (0 .04ng.ml -1 , normal < 0.5 ng.ml­1 ) . There was no post dural puncture headache, neu­rological deficit or evidence of infection.

The patient was discharged on the 11 th post op­erative day, and was asymptomatic as on the last fol­low up visit.


   Discussion Top


The perioperative management of a patient un­dergoing vascular surgery is challenging due to the high incidence of co existing disease, haemodynamic and metabolic stress, ischaemia of the brain, heart or kid­ney which leads to high morbidity during surgery. CEA is generally accepted as the routine method of regional anaesthesia for vascular surgery of the lower limbs . [1] Its drawbacks include technical difficulties of catheter insertion , risks of epidural hematoma in patients with coagulation disorders or who are on anticoagulants and larger anaesthetic dose requirements , catheter tip mi­gration into blood vessel or subarachnoid space . [2] SDSA is effective, rapid, has minimal effect on mental status, reduces blood loss and protects against throm­boembolic phenomenon [4] However SDSA has draw­backs due to its limited duration of action and inci­dence of perioperative hypotension. [1] Continuous spi­nal anaesthesia (CSA), by enabling the reduction and fractionation of the induction dose through a catheter, reduces the haemodynamic consequences of spinal anaesthesia. [5] The slow onset of block of the sympa­thetic system with this technique, allows the cardio­vascular system to adapt more easily , than when the block is more abrupt as in SDSA. [4]

With provision of adequate size catheters , and use of 0.5% bupivacaine , CSA with a lower anaes­thetic dose ,was found to be more rapid in action and produced more pronounced sensorimotor blockage than SDSA and CEA ,with fewer haemodynamic al­terations and side effects [3] Inspite of accidental inser­tion of epidural catheters in the subarachnoid space during anaesthesia , successful outcome without post puncture headaches or infections has been reported .6 In the present case we chose the CSA technique be­cause we desired rapidity of action , and to minimize the dose of anaesthetic agent in this patient with many co morbidities.

The regional anaesthetic agent to be used for CSA, its density, the technique of usage is controver­sial. Isobaric bupivacaine was initially suggested as the preferred anaesthetic agent, as hyperbaricity was be­lieved to result in drug deposition in the spinal cord base 3,7 . However a subsequent study reported that use of hyperbaric bupivacaine lead to a higher level of ana­esthesia, its action reportedly more predictable, mak­ing it possible to control the level of the block by dose and position [4] . We use hyperbaric bupivacaine routinely as the anaesthetic agent for SDSA, without side ef­fects; hence it was preferred for this patient.

There has been only a limited application of CSA due mainly to the lack of adequate spinal catheters, and its implication in specific complications such as in­fection, headache and cauda equina syndrome. [2],[7] The size of catheter was believed to be a determinant fac­tor in the incidence of complications. Fine catheters (28 gauge) were recommended as the quantity and direc­tion of anaesthesia could be controlled. It was believed that injection in a cranial direction by specially designed needles would reduce the chances of deposition of the anaesthetic agents in the region of the cauda equina.[8],[9] Conversely spinal endoscopy and dye studies in vitro have shown that fine catheters may bend during inser­tion , and that the dye injected with smaller bore cath­eters tends to distribute in the dependent portion of the spinal canal.[10] In vivo studies too report that small gauge catheters lead to slow speed of injection due to their high resistance .This caused two major problems in clini­cal settings, the first is inadequate anaesthesia, leading to re injections of large volumes of local anaesthetics which displace cerebro spinal fluid (CSF) preventing dilution by CSF and increasing the concentration of local anaesthetic, leading to neurotoxic effects such as the cauda equina syndrome [3],[7],[11] .The use of larger size catheters has been recommended to avoid these prob­lems[4] Hence we used a 20 gauge size of catheter and were satisfied with the ease of drug administration and intra operative level of block achieved

To conclude, we report the successful anaesthetic management of a patient with ischemia of the right lower limb due to peripheral vascular disease, with multiple co morbid conditions such as coronary artery disease, hypertension and COPD, who underwent a femoro femoral crossover graft. A continuous spinal anaesthe­sia technique, with intermittent bolus of 0.5% bupivacaine was used due to the benefits of its rapidity of action, ability to achieve segmental level and mini­mizing the amount of drugs used.

This technique needs to be in the armamentarium of anaesthesiologists practicing in the high risk setting of vascular surgery.

 
   References Top

1.Norris E J and Frank S M. Anesthesia for Vascular Sur­gery. In Millers RD Ed, Anesthesia ,Volume II, Chapter 51,5 th edition, Churchill Livingstone , Philadelphia 1849 - 1893.  Back to cited text no. 1      
2.Kashanipour A, Strasser K, Klimscha W, Taslimi R, Aloy A, Semsroth M. Continuous spinal anesthesia versus continuous epidural anesthesia in surgery of the lower extremities, A prospective randomized study. Reg Anaesth 1991;14:83-7.  Back to cited text no. 2  [PUBMED]    
3.Klimscha W, Weinstabl C, Ilias W, Mayer N, Kashanipour A, Schneider B, Hammerle A. Continuous spinal anes­thesia with a microcatheter and low-dose bupivacaine decreases the hemodynamic effects of centroneuraxis blocks in elderly patients. Anesth Analg 1993;77:275-80.  Back to cited text no. 3  [PUBMED]    
4.Favarel-Garrigues JF, Sztark F, Petitjean ME, Thicoipe M, Lassie P, Dabadie P. Hemodynamic effects of spinal an­esthesia in the elderly: single dose versus titration through a catheter. Anesth Analg 1996;82:312-6.  Back to cited text no. 4      
5.Pitkanen M, Rosenberg P, Silvanto M, Tuominen M. Haemodynamic changes during spinal anaesthesia with slow continuous infusion or single dose of plain bupivacaine. Acta Anaesthesiol Scand 1992; 36:526-9.  Back to cited text no. 5      
6.Ng A ,Shah Jake , Smith G. Is continuous spinal analgesia via an epidural catheter appropriate after accidental sub­arachnoid administration of 15 mL of bupivacaine 0.1% containing fentanyl 2 micrograms/mL ? Int J Obstet Anesth 2004;13:107-9.  Back to cited text no. 6      
7.Lambert DH, Hurley RJ, Cauda equina syndrome and con­tinuous spinal anesthesia. Anesth Analag 1991: 72: 817­9.  Back to cited text no. 7      
8.Standl T, Eckert S, Rundshager I, Schulter J. A directional Needle improves effectiveness and reduces complica­tions of microcatheter continuous spinal Anesthesia. Canadian J of Anesth 1995; 42:701-5.  Back to cited text no. 8      
9.Standl T, Beck H. Influence of the subarachnoid position of microcatheters on onset of analgesia and dose of plain bupivacaine 0.5% in continuous spinal anesthesia. Reg Anesth 1994;19:231-6.  Back to cited text no. 9  [PUBMED]    
10.Mollman M, Holst D, Enk D, Filler T, et al. Spinal endos­copy in the detection of problems caused by continuous spinal anesthesia Anesthetist 1992;41:544-7.  Back to cited text no. 10      
11.Rigler M L, Drasner K ,Krej C, et al. Cauda equina syn­drome after continuous spinal Anaesthesia. Anesth Analg 1991:72:817-9.  Back to cited text no. 11      




 

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