Year : 2009 | Volume
: 53 | Issue : 4 | Page : 478--481
Combined Spinal Epidural Anaesthesia with BiPAP-Three Case Reports
Ashok Jadon1, Neelam Sinha2, Prashant S Agarwal2,
1 Senior Consultant and Head, Department of Anaesthesia, Tata Motors Hospital, Jam shedpur- 831001, Jharkhand, India
2 P. G Stu dent, Department of Anaesthesia, Tata Motors Hospital, Jam shedpur- 831001, Jharkhand, India
44, Beldih Lake Flats, Dhatkidih, Jamshedpur-831001, , Jharkhand
We report three cases where BiPAP (bi-level positive airway pressure) was used with CSEA (combined spinal epidural anaesthesia) to over come the hypoventilation due to preoperative poor respiratory reserves and additive effect of sedation. Combination of BiPAP with spinal, epidural and CSEA have been used successfully in patients of severe COPD (chronic obstructive pulmonary disease) for various surgical procedures. This combination provides safe alternative to conventional general anaesthesia, as it avoids need for postoperative ventilatory support and its deleterious effects.
|How to cite this article:|
Jadon A, Sinha N, Agarwal PS. Combined Spinal Epidural Anaesthesia with BiPAP-Three Case Reports.Indian J Anaesth 2009;53:478-481
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Jadon A, Sinha N, Agarwal PS. Combined Spinal Epidural Anaesthesia with BiPAP-Three Case Reports. Indian J Anaesth [serial online] 2009 [cited 2021 Jun 13 ];53:478-481
Available from: https://www.ijaweb.org/text.asp?2009/53/4/478/60321
Severe chronic obstructive pulmonary disease (COPD) cases for surgery carry high risk of perioperative morbidity and mortality due to poor respiratory reserve, and associated systemic diseases like hypertension, corpulmonale, CCF (congestive cardiac failure) etc. General anaesthesia if possible, is better avoided due to risk of impending respiratory failure and need for postoperative ventilatory support. , Spinal and epidural anaesthesia provides safe and effective anaesthesia in such high riskpatients.  But problem of intraoperative sedation remain unsolved as sedation may cause hypoxia especially in anxious patients who want to be unconscious and, for laparoscopic procedures where sedation is required to avoid the discomfort of C02 insufl'lation. Upper abdominal operation requires adequate analgesia up to T4 which always compromise on respiratory muscle functions and when sedation is given in already respiratory compromised patients hypoxiais inevitable. However, this hypoxia can be prevented by using intraoperative BiPAP, as it supports the patient's own respiration without interfering airways and preventinghypoxiaby maintaining functional residual capacity(FRC). This concept recently has been used in compromised respiratory system patients ofsevere COPD for various surgical indications. , We reportthe use of a combination of combined spinal ep idural anaesthesia (CSEA) and bilevel positive airway pressure(BiPAP) in three patients of severe COPD for inguinal hernia repair, laparoscopic cholecystectomy and radical hysterectomy.
An 82-yr-male patient presented with obstructed right inguunalhernia. He was a known case ofadvanced COPD, cor-pulmonale and pulmonary artery hypertension. He had very poorrespiratory reserve, he was confined to bed with oxygen support at most of the time of the day, and he was normally unable to lie flat. He had many episodes of CCF and hospitalization in intensive care. Echocardiography showed mild aortic regurgitation with decreased left ventricular function. ECG showed ST depression in inferior leads. Blood investigations and electrolytes were normal.
A 65-yr-female patient presented with gall stones and scheduled for laparoscopic cholecystectomy. She was confined to bed and was under treatment for paraplegia for 2 months, MRI showed compression at D7. She was a case of COPD, old pulmonary tuberculosis, NIDDM on oral hypoglycemic, ischemic heart disease with recurrent chest pain, ECG showed left bundle branch block(LBBB), old anteroseptal infarction with left axis deviation. Echocardiography showed thin and hypokinetic intraventricular septum, mild Lti systolic dysfunction and 44% left ventricular ejection fraction. She had history of untoward cardio-respiratory event under general anaesthesia and intensive care admission (details not available, procedure was abandoned) during Endoscopic Retrograde Cholangiopancreatography (ERCP) for common bile duct (CBD) stent, two weeks before in other hospital.
A 70 yr, 86 kgfemale patient [Figure 1] scheduled for radical hysterectomy. She was a known case of hypertension, diabetes mellitus and COPD and episodes of sleep apnea. She was obese, had difficult airways (MP S 4) and had history of difficulty in maintaining airways under general anaesthesia (midazolam +propofol+ sevoflurane) in last surgery for cervical biopsy 7 days before in our hospital which was managed with bag and mask oxygenation by two anaesthetists.
Informed consent for high risk was taken from patients ,po ssible optimization ofgeneralcondition (antibiotics, insulin, bronchodilators etc.) was done, and medicines were continued as indicated in preoperative period. In operationtheatre standard monitoring was commenced, i.v access established, and an i.v infusion of normal saline solution started. Oxygen was administered through nasal prongs. Combined spinal epidural technique by needle through needle (CSE Cure, Portex Combined Spinal/Epiduralminipack27G/18G) was used for anaesthesia. Epidural catheter (18G) was ins ertedthrough Tuohy needle 3-4cm in epidural space and after negative aspiration testfor blood and CSF 2mlsaline was used to flush the catheter to know the patency. Level of block was decided by nature of operation and epidural top-up were given as required [Table 1]. Sedation was given when patient requested for sleep orshowedundue anxious and uncooperative behavior: Initially with 0.5mg increments ofmidazo lam and 10-20mg bolus of propofoland then infusion of prop ofolwas started @ 0.5mg/kg/hr. BiPAP (BiPAP®Auto-M Series RESPIRONICS®) was started when Sp02 did not improve with oxygen by nasal prongs or Poly mask In first two patients IPAP-14 and EPAP-5 adequately maintained oxygenation, in hysterectomy patient IPAP-20 was required when Sp02 did not improve above 87%. ABGwas done after one hour of BiPAP commencement [Table 2]. BiPAP was gradually with drawn (dependingup on patients' acceptance) and oxygen was continued by Poly mask in postoperative period. Postoperative analgesia was provided with 6m1 epiduralinjection of 0.125% bupivacaine+ buprenorphine 100 -300 lrg on demand basis. All three patients had uneventful recovery and discharged from the hospital.
Spinal and epidural anaesthesia are beneficial for both obese and advanced COPD patients. Compared with general anaesthesia, the maintenance of spontaneous breathing means there is less cephalad displacement of the diaphragm and less risk ofatelectasis, closing capacity and FRC are less affected and pulmonary gas exchange is better maintained .  However, sedation given in conjunction with aregionalblock decreases sensitivity to C02 and hypoxia, and thus these patients are unable to deal effectively with hypercarbiaand hypoxiamoreover, combined effect of pneumoperitoneum (as in laparoscopic cholecystectomy) and sedation can lead to hypoventilation and arterial oxygen desaturation.  Superior postoperative analgesia without risking respiratory depression, and avoidance of the strong stimulation of intubation or the risk of bronchoconstriction on extubation, all of these benefits have been reported in the use of combined spinal and epidural anaesthesiafor abdominal aortic aneurysm repair inpatients with severe COPD. 
We used combination of BiPAP(Bi-level positive airway pres sure) and combined spinal epidural anaesthes is (CSEA) in our three high riskp atients scheduled for inguinalhemia rep air, laparoscopic cholecystectomy and hysterectomy having multiple systemic diseases includingpoorrespiratory reserves due to severe COPD. CS EA is a better option in high risk patients because, it provides safe and effective neuraxialblockthan either spinal orepidural alone.  BiPAP helpedto maintain oxygenation [Table 2] when patients were sedated with propofol and were unable to maintain oxygenation  with conventional methods e.g. nasalprong and Poly mask. General anaesthesia could have been an alternative with intubation and IPPV but there was 1 & elihood that these patients would need postoperative ventilation and, general anaesthesia it self has detrimental effects on postoperative respiratory functions. , Noninvasive ventilation and propofol sedation with spinal, epidural and CSEA has been used and accepted clinically practicable method in various surgical procedures and it helps to conect alveolar hypoventilation during spinal anaesthesia, ,,, There are complications associated withthe use of noninvasive positive pressure ventilation (NIPPV)andthese include local trauma, gastric distension, eye irritation, sinus congestion, air leaks, and haemodynamic effects.  These problems were managed with protective eye pads [Figure 2], nasogastric tube (some time this interfere with airtight seal), extended neck position and selecting lower BiP_AP values (IPAP-14 and 20, EPAP 5-6) and intravenous fluids.
The use of BiPAPfrom beginning of procedure and in a planed manner is ideal to avoid poor patient compliance. This is achieved by acontrolled, gradual introduction, checking the patient's acceptance before peiformingthe spinal, and then the use of target controlled sedation during surgery. 
We report the use of a combination of combined spinal epidural anaesthesia and BiPAP (bi-level positive airway pressure) in three patients of severe COPD who developed hypoventilation when sedation was given This technique helps in managing high nskCOPD patients with advanced lung disease who are at risk of hypoventilation due to sedation under regional anaesthesia.
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