Year : 2008 | Volume
: 52 | Issue : 3 | Page : 324--327
Continuous Spinal Anaesthesia an Underused Technique Revisited: A Case Report
Reena Nayar1, PS Satyanarayana2, Sahajanand3,
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
Department of Anaesthesiology and Intensive Care, St. John«SQ»s Medical College Hospital, Bangalore-560034, Karnataka
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.
|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;52:324-327
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Nayar R, Satyanarayana P S, Sahajanand. Continuous Spinal Anaesthesia an Underused Technique Revisited: A Case Report. Indian J Anaesth [serial online] 2008 [cited 2020 Feb 26 ];52:324-327
Available from: http://www.ijaweb.org/text.asp?2008/52/3/324/60643
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  .
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) , .
We report the use of continuous spinal anaesthesia in a young male with multiple comorbid conditions, undergoing vascular surgery of the lower limb.
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 1 ) . 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.
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 .  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 .  SDSA is effective, rapid, has minimal effect on mental status, reduces blood loss and protects against thromboembolic phenomenon  However SDSA has drawbacks due to its limited duration of action and incidence of perioperative hypotension.  Continuous spinal anaesthesia (CSA), by enabling the reduction and fractionation of the induction dose through a catheter, reduces the haemodynamic consequences of spinal anaesthesia.  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. 
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  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  . 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. , 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., 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. 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 ,, .The use of larger size catheters has been recommended to avoid these problems 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.
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