Thoracic epidural anesthesia in a geriatric patient with cardiac risk: a case report

Serdar Kokulu Remziye Gül Sivaci Gürhan Öz Elif Dogan Baki Hasan Senay Yüksel Ela About the authors

Dear Editor,

With increasing life quality, older population increase fastly. Cardiac and respiratory disorders and autonomic dysfunction seem to occur more frequently in older people.11. Marik PE. Management of the critically ill geriatric patient. Crit Care Med. 2006;34:176-82. Unfortunately this circumstance limits choosing anesthetic methods for these patients. Epidural anesthesia or analgesia can decrease the potential complications due to general anesthesia such as prolonged ventilation, myocardial depression and prolonged ileus.22. Arik H, Erhan OL, Beştas A, et al. The effect of a single or fractional dose of local anesthetic on hemodynamics in epidural anesthesia evaluated according to ejection fraction. Turk J Geriatr. 2012;15:439-44. Fifth cot resection was planned to a 83 years old man with 168 cm height and 68 kg weight due to the chest wall hydatic cysts. His past medical history revealed that he had high degree heart insufficiency, epilepsy, dyspnea and a pacemaker for five years. He had cholecystectomy and inguinal hernia repair surgeries done 20 years and 10 years ago respectively. He was oriented, cooperative and hemodynamically stable. Physical examination revealed basal rales and rhonchi. The ejection fraction was assessed as 33% by echocardiography. He was evaluated as ASA III.

Cardiac treatment was given him according to cardiologist suggestion preoperatively and epidural anesthesia was planned for surgery. No premedication was given before arrival to the operating room. After routine monitoring, peripheral intravenous access was provided and preloading of isotonic solution was given. Epidural catheter was inserted between T4 and T5 intervertebral spaces with a loss of resistance method at sitting position. The catheter tip was set forward to 3 cm cephale and the test dosage of 3 mL 2% Lidocain was applied. Then, 7 mL 5% levobupivacaine and 50 mcg fentanyl were added. Ten minutes later from the application of epidural anesthesia adequate sensorial blockage level was provided between T3 and T8 spaces. Surgical procedure was performed with standard technique at lateral decubitus position. 4 lt/min oxygen was given with a face mask. During surgery, his blood pressures were between 154/94 and 97/54 mmHg, heart rates were 65-108 min-1 and saturations were 89-96%. Approximately 15 min after epidural anesthesia, his blood pressure was recorded as 76/45 mmHg; therefore 5 mg Efedrin was applied intravenously.

Simultaneously evaluated sensorial blockage level was T4. Patient has no additional sedation and analgesia requirements during the surgery which lasted 45 min. He had no respiratory distress intra- and post-operatively. For epidural analgesia 3 mL 5% bupivacaine + 50 mcg fentanyl mixture was applied through the epidural catheter three hours after surgery. Epidural catheter was drawn 24 h later. The patient was discharged with stable vital signs four day after surgery. High thoracic anesthesia (T1-T5) decreases sempatic tone; however dysrhythmia risk is reduced by blockading cardiac accelerator fibers during cardiac surgery.33. Clemente A, Carli F. The physiological effects of thoracic epidural anesthesia and analgesia on the cardiovascular, respiratory and gastrointestinal systems. Minerva Anestesiol. 2008;74:549-63. Niimi et al. reported that high thoracic epidural anesthesia decreased cardiac output but did not affect left ventricular ejection fraction and diastolic filling function.44. Niimi Y, Ichinose F, Saegusa H, et al. Echocardiographic evaluation of global left ventricular function during high thoracic epidural anesthesia. J Clin Anesth. 1997;9:118-24. Rodgers et al. reported that perioperative cardiac complications were less in patients undergoing surgical operations with regional anesthesia.55. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000;16:321.

We applied successful high thoracic epidural anesthesia to our high-risk patient with arrhythmia and low ejection fraction undergoing cot resection.

References

  • 1
    Marik PE. Management of the critically ill geriatric patient. Crit Care Med. 2006;34:176-82.
  • 2
    Arik H, Erhan OL, Beştas A, et al. The effect of a single or fractional dose of local anesthetic on hemodynamics in epidural anesthesia evaluated according to ejection fraction. Turk J Geriatr. 2012;15:439-44.
  • 3
    Clemente A, Carli F. The physiological effects of thoracic epidural anesthesia and analgesia on the cardiovascular, respiratory and gastrointestinal systems. Minerva Anestesiol. 2008;74:549-63.
  • 4
    Niimi Y, Ichinose F, Saegusa H, et al. Echocardiographic evaluation of global left ventricular function during high thoracic epidural anesthesia. J Clin Anesth. 1997;9:118-24.
  • 5
    Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000;16:321.

Publication Dates

  • Publication in this collection
    May-Jun 2014
Sociedade Brasileira de Anestesiologia R. Professor Alfredo Gomes, 36, 22251-080 Botafogo RJ Brasil, Tel: +55 21 2537-8100, Fax: +55 21 2537-8188 - Campinas - SP - Brazil
E-mail: bjan@sbahq.org
Accessibility / Report Error