Rev. Bras. Anestesiol. vol.66 número5

RevBrasAnestesiol.2016;66(5):546---548

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

CLINICAL

INFORMATION

Non-invasive

mechanical

ventilation

and

epidural

anesthesia

for

an

emergency

open

cholecystectomy

Bülent

Serhan

Yurtlu

,

Bengü

Köksal

,

Volkan

Hancı

,

Is

¸ıl

Özkoc

¸ak

Turan

a_{DokuzEylülUniversity,FacultyofMedicine,DepartmentofAnesthesiologyandReanimation,Izmir,Turkey}

b_{BülentEcevitUniversity,FacultyofMedicine,DepartmentofAnesthesiologyandReanimation,Zonguldak,Turkey}

c_{AnesthesiologyandReanimationClinic,IntensiveCareUnit,AnkaraNumuneEducationandResearchHospital,Ankara,Turkey}

Received20March2014;accepted6May2014 Availableonline3June2014

KEYWORDS

Non-invasive ventilation;

Regionalanesthesia; Chronicobstructive pulmonarydisease

Abstract Non-invasiveventilationisanacceptedtreatmentmodalityinbothacute exacerba-tionsofrespiratorydiseasesandchronicobstructivelungdisease.Itiscommonlyutilizedinthe intensivecareunits,orforpostoperativerespiratorysupportinpost-anesthesiacareunits.This reportdescribesintraoperativesupportinnon-invasiveventilationtoneuroaxialanesthesiafor anemergencyupperabdominalsurgery.

©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).

PALAVRAS-CHAVE

Ventilac¸ãonão invasiva;

Anestesiaregional; Doenc¸apulmonar obstrutivacrônica

Ventilac¸ãomecânicanãoinvasiveeanestesiaperiduralemcolecistectomiaaberta

deemergência

Resumo Ventilac¸ão não invasiva é uma modalidade de tratamento aceita tanto em exacerbac¸õesagudasdedoenc¸asrespiratóriasquantoemdoenc¸apulmonarobstrutivacrônica. Écomumenteusadaemunidadesdeterapiaintensivaouparasuporterespiratóriopós-cirúrgico em salas derecuperac¸ão pós-anestesia. Este relato descreve o suporte intraoperatório em ventilac¸ãonãoinvasivaparabloqueiodoneuroeixoemcirurgiaabdominalaltadeemergência. ©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗_{Correspondingauthor.}

E-mails:syurtlu68@gmail.com,syurtlu@hotmail.com (B.S.Yurtlu).

Introduction

The GlobalInitiative forChronic ObstructiveLungDisease defineschronicobstructivepulmonarydisease(COPD)as‘‘a common preventable and treatable disease characterized

http://dx.doi.org/10.1016/j.bjane.2014.05.007

EpiduralanesthesiaandNIV 547

by persistent airflow limitation that is usually progres-siveandassociatedwithanenhancedchronicinflammatory response in the airways and the lung to noxious par-ticles or gases’’.1 _{COPD affects millions of people all} over the world and its rate over the age of 40 years is almost 10%.2_{Therapy ofCOPD patientsis mainly} pharma-cological; non-invasive ventilation (NIV) is an additional tool to increase the survival and improve the quality of life in severe COPD patients.3 _{The role of NIV in the} postoperative course is well described; however knowl-edge on its intraoperative use is limited, and majority of our current knowledge comes from occasional case reports.4---7

A recent systematic review of these case reports aboutNIVapplicationsusedperioperativelyestablishesthat almost all of these reports are related to lower extrem-ity or cesarean surgeries.7 _{One of the main advantages} expectedofNIVapplication istoavoidintubationrelated, commonpulmonarycomplications.Upperabdominalsurgery poses a major risk factor for postoperative pulmonary complications.8 _{The current report describes the use of} NIVthroughouttheupperabdominalsurgeryandsuccessful avoidanceoffurtherrespiratorycomplicationsinaseverely illCOPDpatient.

Case

A46-year-oldmalepatientwasadmittedtoourhospital’s emergencydepartmentwithanupperabdominalquadrant pain.Hisphysicalexaminationandlaboratoryexamination revealedthediagnosisofsubacutecholecystitisandhewas scheduledforanemergencycholecystectomy.

He had been diagnosed with COPD 8 years earlier and wason regular treatment withmedications including furosemide,diltiazem,inhalationalformoterol,budesonide andtiotropiumbromide.Thepatientwashaving supplemen-talO2andusingNIVdeviceathomeforthepastoneyear.

He had bilateral rales and rhonchi onchest examination. He was fully conscious, having supplemental 2lt/min O2

throughnasalcannula,buthisperipheraloxygensaturation (SpO2)was74%.Arterialbloodgas(ABG)analysiswasdrawn

and pulmonary function tests were performed. Results of thepulmonary functiontestswereasfollows:forcedvital capacity 1.62lt (40.7% predicted), and forced expiratory volume in 1s 0.70lt (21.3% predicted), forced expiratory volume in 1s forced vital capacity ratio: 43.1%. Results of preoperative and consecutive ABG analysis are shown in Table 1. Rapid acting bronchodilator, salbutamol and 40mgi.v.prednisolonewereaddedtohistreatment.Despite maximaltherapy,hisrespiratory conditionwasunchanged andhewastransferredtotheoperation theater. Monitor-ing included ECG, SpO2 and non-invasive blood pressure

Table1 Perioperativearterialbloodgasvalues.

pH pO2

(mmHg)

pCO2

(mmHg)

SpO2(%)

Preoperative 7.37 41 49 74 Intraoperative 7.39 48 42 83 Postoperative 7.38 71 48 94

measurement. Heart rate was115beat/min,non-invasive bloodpressurewas162/95mmHgandSpO2was70%during

2lt/min O2 administration withnasal cannula. The radial

arterywas catheterized for invasive blood pressure mea-surementandfurthersampledrawingforarterialbloodgas analysis.Epiduralanesthesiawasdiscussedwiththesurgeon and the patient gave consent to the technique. Epidural catheterwasinsertedthroughtheT8---9interspacewiththe patientinthesittingposition.Afternegativeaspirationof thecatheter,anesthesiawasinitiatedwith3ml%2lidocaine and then established with fractionated administration of 9mlbupivacaineplus50mcgfentanylmixture.Serial exam-inationsofthesensoryblockdevelopmentwereperformed duringepiduraldrugadministration.Whentheupperlevelof thesensoryblockhavereachedT4dermatome,thesurgery wasstarted.Duringthesurgicalprocedure,thepatienthad ventilatory support with in biphasic intermittant positive airwaypressuremodewithhisownNIVdevice.ThesetIPAP was25cmH2O,EPAP6cmH2OandFiO2weresetto35%.ABG

analysiswasmade30minafterNIVapplication,andthedata areshowninTable1.Surgicalprocedurewasaccomplished withinan hourwithoutany complication.The patientwas transferredtointensivecareunit(ICU)andreceived inter-mittentNIV.ResultofABGdrawn1haftertransportationto ICUisshowninthetable.Norespiratoryorsurgical compli-cationwasfoundonthefollow-upatICU.Hewastransferred totheward onthe 3rdpostoperative day and discharged hometwodaysthereafterwithhisregularrespiratory ther-apy.

Discussion

Tothe bestof ourknowledge, thisis thefirst reportthat describesthesuccessfuluse ofNIV togetherwithregional anesthesiaforupperabdominalsurgery.Additional respira-torysupportprovided withNIVimproved oxygenationand gasexchangeduringregionalanesthesiainthispatient.

Upper abdominal surgery is usually performed with generalanesthesia and endotracheal intubation. However residualeffectsofbothgeneralanestheticagentsandpain relatedtosurgerybyitselfinterferewiththefunctions of therespiratorymuscles,increasingtheriskofpostoperative atelectasia and other pulmonary complications.8 _Regional anesthesiamay decrease the rate of postoperative respi-ratorycomplicationsincomparisonwithgeneralanesthesia withendotrachealintubation.

Incaseoflimitedrespiratoryfunctionalreserve,the inci-denceofpotentialpulmonarycomplicationsincreases.9_Itis wellknownthat invasivemechanical ventilationincreases ICU stay and mortality rates in patients with acute exa-cerbationsofCOPD.Anobservationalstudy comparingthe effectivenessofinvasivemechanicalventilationwithNIVin thesetting ofacute exacerbationofrespiratory failurein COPDpatientsindicatesthatitseemstobesafertouseNIV inthissetofpatients.10

548 B.S.Yurtluetal.

epiduralanesthesiaonrespiratorymuscles,ifithadexisted. However,thepatient’swillingnesstoregionalanesthesiaand hiscooperationwiththesurgeonandanesthesiateam pro-videdan additionaladvantagetocomplete the procedure withsuccess.

NIV is an accepted way of treatment in patients with acute respiratory failure.6,11 _{Generally, NIV is not} suit-able for patients with fear of a tight-fitting mask onthe face, who is not able to clear his secretions or who has altered/fluctuating level of consciousness. It is generally appliedintheICU,chestdiseaseswardsortheemergency department.Anesthesiologistsareagroupofphysicianswho areveryfamiliarwithinvasivemechanicalventilationinthe operation theatres and ICUs. Although NIV application in theoperationtheatreisnotausualpractise,itsuseinthe operationtheatre,asinthiscase,carriestheadvantageof continuouspresence of an anesthesiologist, a person who isreadily available torecognizeany problem andprovide furtherrespiratorysupport.Inparallel,thenumberofcase reports describing the use of NIV together with regional anesthesiaisincreasinginrecentyears.5---7,9

In conclusion, NIV is applicable with thoracic epidural anesthesiafor emergentupper abdominal surgery and its usehaspreventedaprobableprolongedICUstaydueto inva-sivemechanicalventilation.Thereisaneedforrandomized prospectiveclinical trialsin patients withhigh pulmonary complications risk to find out whether NIV together with regional anesthesia provides an advantage over general anesthesiawithendotrachealintubation.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

AuthorsthankDr AliU˘gurEmre,Assoc.Prof.DrofGeneral SurgeryatBülentEcevitUniversity,forhisharmonywiththe anesthesiateamduringtheoperationofthispatient

References

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