Thoracic combined spinal-epidural anesthesia for laparoscopic cholecystectomy in an obese patient with asthma and multiple drug allergies: a case report

Case report

Our patient, a 34-year-old female ASA III, was scheduled for elective laparoscopic cholecystectomy because of repetitive biliary colic episodes present for past 2 months. She was referred to our department after she was disqualified from general anesthesia in two other hospitals. The patient was obese, her body mass index (BMI) was 47 (127.5 kg, 168 cm), and she suffered from many comorbidities. She had arterial hypertension treated with telmisartan, furosemide, and clonidine, bronchial asthma controlled with salmeterol and fluticasone, and stage 3 chronic kidney disease (cyclosporine-induced nephropathy). She also suffered from atopic dermatitis (treated with cetirizine, steroids, and cyclosporine, which resulted in nephropathy) and multiple drug allergies. She also experienced anaphylactic shock (presumably induced by drugs) in her history. Drug allergies were diagnosed and confirmed by an appropriate allergological assessment. The patient was allergic to atropine, midazolam, ethomidate, fentanyl, tramadol, suxamethonium, vecuronium, cisatracurium, and metamizole. Allergy to lidocaine and bupivacaine was ruled out.

We decided that standard general anesthesia was not a safe choice in this particular case, especially due to the limited drug choice and the history of anaphylactic shock. Therefore, after discussing possible options with both the patient and the surgeons, we decided to perform thoracic combined needle through needle spinal-epidural (CSE) anesthesia according to the experience of van Zundert’s group [1, 2]. After the decision, the patient was prepared for the surgery by the bariatric team in cooperation with nephrologists. We wanted to keep the insufflation pressure during laparoscopy as low as possible, without worsening surgical conditions, so during 1 week of preoperative management a preoperative energy restrictive diet was introduced to reduce the liver and intraabdominal adipose tissue volume, to reduce intraabdominal pressure, and to facilitate laparoscopic surgery with pneumoperitoneum with lower inflation pressure. Our aim was not to exceed 12 mmHg. The management was successful and the patient lost 7 kg before the surgery.

Because of the morbid obesity of the patient, there was a high risk of laparoscopy failure and a need to converse to classic laparotomy. We anticipated this risk so we planned an anesthetic rescue strategy if this situation would occur. We planned combining thoracic epidural anesthesia with volatile induction of light general anesthesia with sevoflurane combined with low doses of ketamine intravenously. Airway would be secured with a laryngeal mask airway (the LMA ProSeal). The LMA ProSeal is equipped with an additional channel that allows the suctioning of gastric contents. It is also designed to effectively protect the airway with 50% higher peak ventilatory pressures without a leak compared to a standard laryngeal mask airway. We would also consider starting intravenous lidocaine infusion in case of nonadequate anesthesia, as allergy to lidocaine was excluded. If this strategy failed and airway pressure would exceed 30 mm H₂O, the patient would be intubated in deep inhalational anesthesia combined with intravenous ketamine. Surgical muscle relaxation was achieved by spinal anesthesia and basic analgesia by CSE anesthesia.

The surgery was elective and our selected anesthesia method was crucial for the whole management, so if it would fail we would try again to achieve a working, efficient CSE anesthesia. If the state of the patient would deteriorate and the procedure would become urgent, than we would perform volatile induction and maintenance of anesthesia with a high concentration of volatile anesthetic to achieve a sufficient degree of muscle relaxation (but without serious hypotension) combined with ketamine and lidocaine both intravenously and local for analgesia and β-blockers for stabilizing cardiovascular response to surgical stimuli. This would only be done in an emergency situation, as it is far from ideal anesthesia but would avoid risking anaphylaxis.

The patient was given no premedication before arriving to the theater, as she was allergic to midazolam. With the patient in a sitting position, the 18 G Tuohy epidural needle (Espocan+Docking System, B.Braun Melsungen, Germany) was aimed to insert at the 10th thoracic interspace. After the identification of the epidural space (loss of resistance technique), a 27 G pencil point Whitacre spinal needle was inserted. After obtaining a free flow of the cerebrospinal fluid (CSF), 1.3 mL plain bupivacaine 0.5% with 0.2 mL clonidine (30 μg) was slowly injected. Then, a 20 G epidural catheter was inserted and the patient was placed supine. The evaluation of sensory block with the pinprick method after 5 min showed a segmental block extending between the first lumbar (L1) and the second thoracic (Th2) dermatomes. There were no signs or complaints of respiratory distress. The patient could move her legs and hip flexion was also possible. Oxygen (4 L min⁻¹) was given through a facemask. After appropriate insufflation, a 10 mm scope (Elvis Exera II, Olympus, Japan) was inserted and the abdomen was visually inspected to be benign in gross visualization. Next, three ports were placed in the typical regions. The gallbladder was easily identified. Upon the retraction of the gallbladder, the cystic duct was identified, clipped, and transected. Next, a procedure on a cystic artery was performed in the way described above. Following this, the gallbladder was easily retracted back and electrocautery was used to dissect the gallbladder fossa. The gallbladder was placed in the endobag and removed. The supraumbilical fascia was closed in a simple interrupted manner and the skin was closed. Sterile dressings were placed on the incision sites.

The blood pressure decreased from 190/150 to 120–130/80 mmHg at the beginning of the surgery and the heart rate decreased from 90 to 70 beats min⁻¹ and remained stable during the surgery (Figure 1). During the operation (lasted 65 min), 1000 mL of crystalloid were given intravenously. After 35 min of surgery, the patient complained of pain in the right shoulder. She was given ketamine 15 mg intravenously twice [3], and the subphrenic instillation of bupivacaine 0.25% above the liver was performed by the surgeon. Surgical conditions were acceptable for the surgeons and comfortable for the patient. At the end of the operation, the same extent of sensory block was present. The patient was able to move herself from the operation table to her bed. Once the sensory block subsided and there were no neurological sequelae, the continuous infusion of bupivacaine 0.125% was started at 6 mL h⁻¹. The postoperative period was uneventful, and 3 days later, the patient was discharged home.

Figure 1:

Allergological assessment.

Cholecystectomy is usually performed under general anesthesia, but in some cases it is impossible or too dangerous for the patient. Our report proves that there is an alternative way to achieve a sufficient and comfortable anesthesia for both the patient and the surgeons using regional techniques.

Thoracic epidural anesthesia is not considered a safe technique. The two main concerns are a greater risk of damaging the spinal cord with the needle during the dura puncture and ventilatory impairment caused by an extensive thoracic nerve block. According to van Zundert’s group [1, 2], the distance between the dura mater and the spinal cord in the middle to the lower thoracic level is greater than the size of epidural space, at the same level allowing an experienced clinicist to perform safe spinal anesthesia. The incidence of paraesthesia is lower than expected and usually a response to simply withdrawing the needle [2], but it should be always taken into consideration that there is a possibility of damaging the spinal cord [2, 4].

As for ventilatory impairment, it is true that blocking the thoracic nerves will affect the strength of abdominal wall muscles and impair cough and forceful expiration, but the main respiratory muscle, the diaphragm, stays unaffected, as its main innervation comes from cervical nerves. We used a small amount of plain bupivacaine 0.5% combined with clonidine (1.5 mL) to reduce the impact of the block on respiratory function, and it was sufficient enough for our patient to receive oxygen 4 L/min via facemask to maintain saturation in range of 95%–97% (Figure 2), although she suffers from asthma and is extremely obese. There is, however, a potential risk of inducing respiratory distress, especially in patients with respiratory diseases such as asthma and chronic obstructive pulmonary disease and if the patient is using active expiration to maintain proper ventilation. Therefore, potential risks and benefits should be estimated for every patient individually. Another important thing is maintaining a proper pressure of pneumoperitoneum, which can be difficult because a compromise between the comfortable operating conditions for the surgeons and a satisfactory function of diaphragm is necessary.

Figure 2:

Anaesthetic chart.

We decided to perform thoracic CSE anesthesia instead of other possible solutions because thoracic epidural anesthesia is routinely used in our department, so we are familiar with this technique and we also wanted to provide not only a suitable surgical anesthesia but also a comprehensive postoperative pain management for our patient.

In conclusion, thoracic CSE anesthesia could be an alternative to general anesthesia for cholecystectomy, especially in patients with contraindications – severe respiratory diseases [1] or drug allergies – but only with individual evaluation of the patient and a properly experienced clinicist.