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LETTERS TO EDITOR
Year : 2017  |  Volume : 18  |  Issue : 2  |  Page : 90-91
 

Successful combined spinal–Epidural anesthesia for a case of scleroderma for amputation


Department of Anaesthesia, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India

Date of Web Publication12-Dec-2017

Correspondence Address:
Dr. Bhavna Kakkar
Department of Anaesthesia, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_17_17

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How to cite this article:
Kakkar B, Govil NP, Saith V, Agarwal M. Successful combined spinal–Epidural anesthesia for a case of scleroderma for amputation. Indian Anaesth Forum 2017;18:90-1

How to cite this URL:
Kakkar B, Govil NP, Saith V, Agarwal M. Successful combined spinal–Epidural anesthesia for a case of scleroderma for amputation. Indian Anaesth Forum [serial online] 2017 [cited 2019 Aug 25];18:90-1. Available from: http://www.theiaforum.org/text.asp?2017/18/2/90/220551


Sir,

A 48-year-old female weighing 40 kg, height 150 cm, was posted for bilateral lower limb debridement and revision amputation. She was a known case of scleroderma and had multiple comorbidities including chronic dyspepsia, dilated cardiomyopathy (DCMP), severe systolic dysfunction (ejection fraction 25%–30%), interstitial lung disease [Figure 1], and severe restriction in the pulmonary function test and Raynaud's phenomenon. Three months back, she had acute limb ischemia and gangrene of the forefoot and underwent transmetatarsal amputation under the ankle block. She subsequently developed wet gangrene in the bilateral lower limb up to the level of mid-leg; she was posted for amputation and debridement of the wound to contain the source of sepsis. On examination, she had waxy, thick, shiny skin, telangiectasia, oral ulcers and beefy red tongue, shortened and sausage-like fingers, with flexion contractures [Figure 2], mouth opening 1.5 finger breadth [Figure 3], respiratory rate 40/min, heart rate 150/min, blood pressure 80/48 mmHg, and decreased air entry in both lungs. She had moderate anemia (hemoglobin 8 g/dl) and raised leukocyte count. Our plan of anesthesia was combined spinal–epidural (CSE) anesthesia; however, all general anesthesia drugs and equipment were kept ready. The patient was shifted to prewarmed operation theater, routine monitors were attached, and saturation probe was put on the ear lobule as there was skin thickening and vasospasm in fingers. The patient was preloaded with 350 ml Ringer lactate, epidural was placed at L1 vertebra, and catheter was fixed at 8 cm, and test dose was omitted initially. Subarachnoid block was provided by 4 mg hyperbaric bupivacaine hydrochloride (0.8 cc) and 10micrograms fentanyl (0.2 cc) and sensory level was achieved at T8 dermatome. The patient demanded rescue analgesia after 65 min, and we gave epidural test dose 3 cc plain xylocaine and sensory level was achieved at T10, second and third rescue came after 45 and 55 min, respectively, and the same were provided with 3 cc xylocaine. Estimated blood loss was about 100 ml under tourniquet, and she received 800 ml crystalloids and 100 ml packed cell volume to replace the lost blood volume in view of moderate anemia and DCMP. General care included careful positioning, padding to avoid pressure necrosis, warm operation theater, and warm intravenous fluids.
Figure 1: Chest X-ray showing increased interstitial markings suggesting interstitial lung disease

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Figure 2: Our patient had sausage-like digits with atrophic changes and discoloration, and peripheral saturation could not be read on the digital tips

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Figure 3: Typical mask-like facies and microstomia suggesting difficult airway

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Whenever feasible, regional anesthesia is the preferred technique in scleroderma owing to the risk of aspiration, difficult airway, and cardiorespiratory impairment during general anesthesia. However, these patients have a risk of prolonged blockade due to fibrosis of tissues surrounding the peripheral nerve and a rise in the overall compartment pressure on injection of local anesthesia (LA).[1] We avoided bilateral peripheral nerve blockade to avoid the use of a large volume of LA and blockade failure, or LA excess could have called for an emergency intubation in difficult airway. We avoided radial artery cannulation due to Raynaud's phenomenon. Blind central line placement was not done to avoid inadvertent arterial puncture. They have contracted intravascular volume and may manifest with sudden hypotension on induction or subarachnoid blockade, which might be unresponsive to vasopressors; hence, adequate preloading is important. We gave low volume of drug in the subarachnoid space and 9 cc plain-xylocaine (including test dose) for top-up in the epidural space titrating to blockade for 4-h duration. Although there are no contraindications to the type of anestheia, CSE provided excellent anesthesia and analgesia in the perioperative period; however, one must be cautious to avoid hemodynamic changes and extent of blockade as a result of disease entity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Roberts JG, Sabar R, Gianoli JA, Kaye AD. Progressive systemic sclerosis: Clinical manifestations and anesthetic considerations. J Clin Anesth 2002;14:474-7.  Back to cited text no. 1
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