|Year : 2016 | Volume
| Issue : 1 | Page : 14-16
Combined spinal–epidural anesthesia for an elderly patient with proportionate dwarfism for laparotomy
Teena Bansal, Rajmala Jaiswal, Arnab Banerjee
Department of Anaesthesiology and Critical Care, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
|Date of Submission||15-Mar-2016|
|Date of Acceptance||22-Apr-2016|
|Date of Web Publication||17-Jun-2016|
2/8, FM, Medical Campus, PGIMS, Rohtak - 124 001, Haryana
Source of Support: None, Conflict of Interest: None
Anesthesia in a dwarf patient may be challenging as various anatomical anomalies make both general and regional anesthesia difficult. These patients may have atlantoaxial instability, potential for airway obstruction, and associated respiratory problems that may pose problems for general anesthesia. Spinal stenosis, osteophytes, short pedicles, or a small epidural space could complicate regional anesthesia in dwarfs which could lead to difficulties in locating the epidural space and increase the risk of dural puncture. Spinal stenosis may impair cerebrospinal fluid flow such that identification of dural puncture is difficult. This elderly dwarf patient had history of bronchial asthma with restriction of neck extension, managed successfully using combined spinal–epidural anesthesia.
Keywords: Combined spinal–epidural, ovarian mass, proportionate dwarfism
|How to cite this article:|
Bansal T, Jaiswal R, Banerjee A. Combined spinal–epidural anesthesia for an elderly patient with proportionate dwarfism for laparotomy. Indian Anaesth Forum 2016;17:14-6
|How to cite this URL:|
Bansal T, Jaiswal R, Banerjee A. Combined spinal–epidural anesthesia for an elderly patient with proportionate dwarfism for laparotomy. Indian Anaesth Forum [serial online] 2016 [cited 2020 Nov 27];17:14-6. Available from: http://www.theiaforum.org/text.asp?2016/17/1/14/183578
| Introduction|| |
Dwarfism is failure to achieve a height of 148 cm by childhood. People with short stature have been categorized as those with proportionate growth (a normal ratio of trunk-to-limb length) and another one with disproportionate development. Dwarf patients may present with various problems for both general and regional anesthesia. They may have difficult airway and respiratory problems thereby causing difficulty for general anesthesia. Spinal abnormalities may pose technical difficulty in locating the epidural space. Further, these patients may have narrow spinal canal and epidural space thereby requiring lesser doses of drugs. Anesthesia in such a situation may be challenging where a dwarf patient is elderly too. We hereby present a case report of an elderly patient with proportionate dwarfism undergoing laparotomy for the removal of large ovarian mass.
| Case Report|| |
An 80-year-old elderly female weighing 42 kg was scheduled for exploratory laparotomy for large ovarian mass. She had proportionate dwarfism (height 130 cm) [Figure 1]. She had a past history of bronchial asthma for which she was taking inhalation therapy with a combination of beta-2 agonist and steroids. On general physical examination, pulse was 94/min and blood pressure was 136/86 mmHg. On systemic examination, air entry was mildly decreased bilaterally and heart sounds were normal. Airway evaluation revealed Mallampati Grade III with restriction of neck extension. Relevant investigations including hemoglobin, bleeding time, clotting time, urine examination, blood urea, blood sugar, chest X-ray, and electrocardiogram were normal. International normalized ratio was 1.1. Pulmonary function test revealed mild obstructive airway pattern, reversible with bronchodilator therapy. X-ray of the cervical spine showed changes of diffuse osteoarthritis with reduced disc spaces without any atlantoaxial fusion. Computed tomography scan of the abdomen revealed a bilateral ovarian mass of sizes 10 cm × 8 cm on the right side and 8 cm × 6 cm on the left side.
In view of difficult airway, history of bronchial asthma, and to avoid postoperative pulmonary complications, combined spinal–epidural anesthesia was planned for the procedure. The anesthetic procedure was explained to the patient and high-risk consent for anesthesia was obtained. In the operating room, standard monitors were attached. Intravenous line was secured with 18 gauge cannula using Ringer lactate. In sitting position, 2 ml of 0.5% bupivacaine heavy along with 25 μg fentanyl was given in L4–5 subarachnoid space and 18 gauge epidural catheter was inserted in L3–4 interspace and fixed. Adequate sensory block was achieved up to T6 level. Intraoperatively the patient developed 84/60 hypotension which was treated with fluids and mephentermine. A large ovarian mass weighing 5.2 kg was removed. Surgery lasted for 2 h. Postoperatively a test dose of 2 ml of 2% xylocaine with adrenaline was given to rule out intravascular or subarachnoid placement. Postoperative analgesia was provided with 25 mg of tramadol diluted to 8 ml of saline for next 48 h and the patient remained comfortable. The patient was discharged on the 8th postoperative day in stable condition.
| Discussion|| |
Age increases the probability of a person to undergo surgery. Perioperative morbidity becomes more frequent in the elderly with steep increases after the age of 75. The situation becomes more problematic if the patient is dwarf too. Elderly dwarf patient poses a specific challenge to the anesthesiologist whose role might extend from perioperative physician to palliative care provider. The incidence of perioperative complications is much higher in these patients due to reduced functional reserve and a high incidence of comorbidities. The elderly are more sensitive to anesthetic agents and generally require smaller doses for the same clinical effect and drug action is usually prolonged. Therefore, all aspects of anesthesia, i.e., perioperative management, type of anesthetic technique, and choice of anesthetic agents, require careful consideration in elderly patients.
Dwarf patients present several problems for general anesthesia. These patients may have atlantoaxial instability, potential for airway obstruction, and associated respiratory problems that may pose problems for general anesthesia. Atlantoaxial instability is found in 75% of nonachondroplastic dwarf and utmost care should be taken during intubation. We avoided general anesthesia in view of anticipated difficult intubation due to restricted neck extension and also to avoid postoperative pulmonary complications as the patient had bronchial asthma. In addition to providing the benefit of postoperative analgesia, combined spinal–epidural anesthesia was chosen.
Nandini et al. reported the use of combined spinal–epidural anesthesia for the removal of bilateral ovarian masses by laparotomy in a patient with proportionate dwarfism. Although we did not find any difficulty in locating the epidural space and performing lumbar puncture, spinal stenosis, osteophytes, short pedicles, or a small epidural space could complicate regional anesthesia in dwarfs which could lead to difficulties in locating the epidural space and increase the risk of dural puncture. Further, the presence of narrow epidural space makes insertion of epidural catheter difficult. The risk of venous puncture is increased due to engorged epidural veins either by Touhy needle or by the catheter. These patients have reduced epidural dose requirements due to narrow spinal canal and epidural space. Hence, we used tramadol in low doses. Spinal stenosis may impair cerebrospinal fluid flow such that identification of dural puncture is difficult. Repeated dry taps have been reported while performing lumbar puncture in an achondroplastic dwarf.
We chose combined spinal–epidural anesthesia technique as it offers advantages over the epidural or single-injection spinal anesthesia alone. It combines the rapidity, density, and reliability of subarachnoid block with the flexibility of epidural catheter to titrate the desired level, vary the density of the block, control the duration of anesthesia, and deliver postoperative analgesia. We used fentanyl as adjuvant opioids in conjunction with local anesthetics decrease the dose of local anesthetic and improve the quality of intraoperative analgesia.
The present case report describes the successful result of combined spinal–epidural anesthesia for major abdominal, gynecological surgery in an elderly patient with proportionate dwarfism.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nandini D, Kumar S, Sushma W. Combined spinal epidural anaesthesia for removal of bilateral ovarian masses by laparotomy in a patient with proportionate dwarfism. Indian J Anaesth 2006;50:304-7.
Berkowitz ID, Raja SN, Bender KS, Kopits SE. Dwarfs: Pathophysiology and anesthetic implications. Anesthesiology 1990;73:739-59.
Bansal T, Malhotra N, Hooda S. Anaesthetic considerations in elderly. Int J Pharma Bio Sci 2012;3:141-50.
Perovic MN, Kopits SE, Thompson RC. Radiological evaluation of the spinal cord in congenital atlanto-axial dislocation. Radiology 1973;109:713-6.
Carstoniu J, Yee I, Halpern S. Epidural anaesthesia for caesarean section in an achondroplastic dwarf. Can J Anaesth 1992;39:708-11.
Cevik B, Colakoglu S. Anesthetic management of achondroplastic dwarf undergoing cesarean section – A case report. Middle East J Anaesthesiol 2010;20:907-10.
Saxena KN, Kapoor D, Taneja B, Maini L, Hora S. Anaesthetic management of caesarean section in an acondroplastic dwarf. Indian J Anaesth 2008;52:844-8.
Chandola HC, Mohamed ZU, Pullani AJ. Combined spinal-epidural anaesthesia techniques. A review. Indian J Anaesth 2005;49:450-8.
Gupta S, Sampley S, Kathuria S, Katyal S. Intrathecal sufentanil or fentanyl as adjuvants to low dose bupivacaine in endoscopic urological procedures. J Anaesthesiol Clin Pharmacol 2013;29:509-15.