RevBrasAnestesiol.2016;66(4):423---425
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Anesthetic
management
of
nephrectomy
in
a
chronic
obstructive
pulmonary
disease
patient
with
recurrent
spontaneous
pneumothorax
Mysore
Chandramouli
Basappaji
Santhosh
∗,
Rohini
Bhat
Pai,
Raghavendra
P.
Rao
DepartmentofAnesthesiology,SDMCollegeofMedicalSciencesandHospital,Dharwad,Karnataka,India
Received4December2013;accepted5February2014 Availableonline12March2014
KEYWORDS
Chronicobstructive pulmonarydisease; Pneumothorax; Nephrectomy; Regionalanesthesia
Abstract Nephrectomies areusually performedunder generalanesthesiaalone orin com-binationwithregionalanesthesiaandrarelyunderregionalanesthesiaalone.Wereportthe managementofapatientwithchronicobstructivepulmonarydiseasewithahistoryofrecurrent spontaneouspneumothoraxundergoingnephrectomyunderregionalanesthesiaalone. ©2014SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
PALAVRAS-CHAVE
Doenc¸apulmonar obstrutivacrônica; Pneumotórax; Nefrectomia; Anestesiapor conduc¸ão
Controleanestésicodenefrectomiaempacientecomdoenc¸apulmonarobstrutiva
crônicaepneumotóraxespontâneorecorrente
Resumo Geralmente, asnefrectomiassão feitassob anestesia geral, isoladamenteou em combinac¸ãocomanestesiaregional,eraramentesobanestesiaregionalsozinha.Relatamoso tratamentodeumpacientecomdoenc¸apulmonarobstrutivacrônicaehistóriadepneumotórax espontâneorecorrentesubmetidoànefrectomiasobanestesiaregionalisolada.
©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigo OpenAccess sobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Upper abdominal surgeries, advanced age, and chronic obstructivepulmonarydiseaseareamongthemost
impor-∗Correspondingauthor.
E-mails:mcbsanthu@gmail.com,mcbsanthu@yahoo.in (M.C.B.Santhosh).
tant predictors of high risk for postoperative pulmonary complications.1Inachronicobstructivepulmonarydisease (COPD) patient, maintenance of spontaneous respiration withregionalanesthesiahas been found to beassociated withbetterpost-operativepulmonaryfunction.2Mostofthe upperabdominal surgeries,especially nephrectomies, are performedundergeneralanesthesiaaloneorincombination withregionalanesthesiabecauseofsurgicalpositionofthe patient(lateraldecubituswithkidneybridge)andprolonged
http://dx.doi.org/10.1016/j.bjane.2014.02.002
424 M.C.B.Santhoshetal.
durationofsurgeries.Veryfewcasesofnephrectomyhave beendescribedusingregionalanesthesiaalone.3,4Wereport apatientwithCOPD,withpast history ofrecurrent spon-taneouspneumothorax,postedfor nephrectomy,managed underregionalanesthesiaalone.
Case
report
A 60-year-oldman diagnosed with a huge hydronephrotic leftkidneywaspostedfornephrectomy.Preanesthetic eval-uation revealed that patient was treated for pulmonary tuberculosis three years ago. Patient was a known case of COPD and had three episodes of spontaneous tension pneumothoraxinthepastoneyearwhichrequired hospital-izationandintercostaldrainage(ICD)insertion.Thepatient hadnoothercoexisting diseases. Onexamination, hewas 175cmtall,weighed60kgandhadgrade3clubbingofall fingers.Trachea wasshifted toleftand therewere three scarsintherightinfraaxillaryregionduetothepreviousICD insertions.Bronchial breathsoundswereheard inthe left infraclavicular and axillary regions. Chest roentgenogram showedfibrosisintheupperlobeofleftlungand compen-satoryemphysematouschange intheright lung.CTthorax confirmedthe chestroentgenogram findings. CTabdomen showedahugehydronephroticleftkidneyoccupyingmore thanhalfoftheabdomen.Otherinvestigationswerewithin normallimit.
Patient was explained about the options of anesthe-sia for the above surgery and also about the possible complications with general anesthesia and advantages of regional anesthesia in view of his respiratory problems. Thepatientagreedfor regionalanesthesia.The samewas discussed with the surgeon. A combined spinal epidural anesthesia was planned. Patient was premedicated with Tab.Alprazolam (0.5mg PO)at nightand the morning of surgery.
Intheoperationtheatre,afterinitiatingstandard mon-itoring, under aseptic precautions, in sitting position, epidural space was identified by loss of resistance to air technique with 18G Tuohy needle at T7-8 level and 20G epidural catheter was inserted and fixed at 8cm. Underasepticprecautions,at L2-3spacelumbarpuncture was done with 26G Quincke’s needle and 3.5mL of 0.5% BupivacaineHeavy wasinjected intrathecally. Withspinal anesthesia, sensory block up to T8 was achieved. Epidu-ralbolusof8mLof0.5%Bupivacainewasgiventoachieve anesthesiaup to T4 level. Epidural anesthesiawas main-tained with epidural infusion of 0.5% Bupivacaine at the rateof8mL/h.Patientwaspositionedinrightlateral posi-tion for removal of grossly enlarged hydronephrotic left kidney.Nephrectomy lastedfor fourhoursand anesthesia was adequate throughout the surgery. Patient was com-fortable throughout the intraoperative period and there werenomajorhaemodynamicorrespiratorychanges. Post-operatively patient was shifted to ICU for monitoring. Postoperativeanalgesiawasmaintainedwithepidural infu-sionof 0.125% Bupivacaine+Inj. Fentanyl 2g/mL at the
rateof 6mL/h. On thesecond postoperativeday, patient developedsuddenbreathlessnesswithpainintherightside ofthe chestand decreasein oxygensaturation. Clinically and radiologically it was diagnosed aspneumothorax and
wastreatedwithimmediateICDinsertion.Patientwas con-tinued to be monitored in the ICU and was shifted out of the ICU onthe 10thpostoperative day withnofurther complications.
Discussion
Nephrectomies areusuallyperformedundergeneral anes-thesia alone or in combination with regional anesthesia becauseofthesurgicalposition,durationofsurgery.
Ourpatientwasa knowncase of COPDwithhistory of recurrent spontaneous pneumothorax. The most common cause of secondary spontaneous pneumothorax is chronic obstructivepulmonarydisease,whichaccountsfor approx-imately 70% of the cases.5 Once a second episode has occurred, there is a high likelihood of subsequent fur-ther episodes.6 Pneumothorax is a potentially dangerous problem, especially during general anesthesia, as posi-tive pressure ventilation increases the risk of a tension pneumothorax.7 Ourpatient had three episodes of pneu-mothoraxinthepastwhichmadehimhighriskforgeneral anesthesia. Hence we decided to perform the surgeries under regional anesthesia alone. We decided to proceed withcombinedspinal-epiduralanesthesiaforthe nephrec-tomybecausethespinalanesthesiaprovidedafasteronset ofanesthesiasafelyuptoT6-8withgoodmusclerelaxation andwecouldachievethehigherlevelandalsofurther main-tainanesthesiathroughthecontinuousepiduralanesthesia. Inour patient,the intraoperative periodwas unevent-ful, but on the second postoperative day the patient developed spontaneous tension pneumothorax which was recognisedand treatedearly.Such eventcouldhave hap-pened intraoperatively morereadily ifgeneral anesthesia withintermittentpositivepressureventilationwas adminis-tered.Theuseofregionalanesthesiainthispatientavoided sucheventsintraoperatively.
Conclusion
Positionofthepatientforthesurgery,prolongeddurationof surgery,andneedforgoodrelaxationmakemost anesthesi-ologiststochoosegeneralanesthesiawith/withoutregional anesthesia for nephrectomies. In selected cases such as ours, where the benefits of regional anesthesia outweigh theadvantagesofgeneralanesthesia,nephrectomiescanbe performedunderregionalanesthesiaalone,afteradequate patientcounseling.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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