|Year : 2019 | Volume
| Issue : 2 | Page : 97-99
Cervical epidural anesthesia for radical mastectomy in an elderly patient with severe respiratory compromise
Vikas Gogia1, Chitra Chatterji1, Ramesh Sarin2
1 Department of Anaesthesia and Critical Care, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India
2 Department of Surgical Oncology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India
|Date of Submission||17-Jan-2018|
|Date of Acceptance||11-May-2019|
|Date of Web Publication||19-Jun-2019|
House No. 782, Sector 28, Faridabad - 121 008, Haryana
Source of Support: None, Conflict of Interest: None
Cervical epidural anesthesia for breast surgery has been described in a few trials on patients with good physical status. This case report describes the successful use of cervical epidural anesthesia in a patient with severe respiratory compromise without any complication. A 72-year-old female patient having infiltrating duct carcinoma of the right breast with coexisting chronic obstructive airway disease and bronchial asthma was planned for modified radical mastectomy with axillary clearance. Her forced vital capacity (VC) was 28% predicted with reversibility of 24% and forced expiratory volume in 1 s was 31% predicted with 35% reversibility. After discussion with the surgical team, a regional anesthetic was planned for the patient and a cervical epidural catheter placed at C7–T1 interspace was used to provide adequate dermatomal anesthesia for the surgery. Dexmedetomidine was used to achieve sedation for patient comfort with minimal respiratory depression. The SpO2 and end-tidal CO2 recordings remained stable throughout the procedure, with excellent intra- and postoperative analgesia. Despite the concerns of bilateral phrenic nerve palsy with the use of cervical epidural anesthesia and associated decrease in VC, a carefully conducted cervical epidural anesthesia can be used for patients with respiratory compromise undergoing major breast surgery. Radical mastectomy, cervical epidural anesthesia, low FEV1, FVC, dexmedetomidine.
Keywords: Cervical epidural anesthesia, dexmedetomidine, forced vital capacity, low forced expiratory volume in 1 s, radical mastectomy
|How to cite this article:|
Gogia V, Chatterji C, Sarin R. Cervical epidural anesthesia for radical mastectomy in an elderly patient with severe respiratory compromise. Apollo Med 2019;16:97-9
|How to cite this URL:|
Gogia V, Chatterji C, Sarin R. Cervical epidural anesthesia for radical mastectomy in an elderly patient with severe respiratory compromise. Apollo Med [serial online] 2019 [cited 2020 Jan 17];16:97-9. Available from: http://www.apollomedicine.org/text.asp?2019/16/2/97/260689
| Introduction|| |
The traditional anesthetic approach for radical breast surgery has been general anesthesia with postoperative analgesia being taken care of with systemic opioids and nonsteroidal anti-inflammatory drugs. There have been various studies and case reports describing the use of regional techniques for either postoperative analgesia or as the sole anesthetic technique for this surgical procedure. The most common techniques used in clinical practice are thoracic paravertebral blocks and intrapleural analgesia techniques. Cervical epidural anesthesia is the most likely to obviate the need for general anesthetic supplementation as it can achieve a dermatomal spread from C3 to T8 with safely permitted doses of local anesthetics and allow axillary dissection which is an integral part of radical mastectomies.
There have been studies assessing the feasibility of cervical epidural anesthesia as the only anesthesia for this surgery, but the patients selected were of the American Society of Anesthesiologists (ASA) Grade I or II. Hence, the benefit of replacing general anesthesia with regional techniques has not been assessed so far in sick patients, i.e., ASA III or IV patients who should actually get the benefit of regional techniques, thus reducing perioperative morbidity in this “high-risk group.” More important is the use of regional anesthesia in patients with a poor respiratory reserve who have a high rate of postoperative complications following a general anesthetic.
| Case Report|| |
A 72-year-old female patient having infiltrating duct carcinoma (IDC) of the right breast was posted for modified radical mastectomy with axillary clearance. The patient was a known case of chronic obstructive airway disease with bronchial asthma for the past 40 years and was receiving Deriphyllin, Mucolite, Flohale, Foratec, and Duolin nebulization. The patient was also on domiciliary oxygen therapy and was requiring 4–5 l of oxygen in the preoperative period. The patient complained of breathlessness on mild exertion such as level walking and going to the toilet.
On examination, the patient was a frail elderly lady, with a height of 145 cm, and she weighed 34 kg. Her airway examination was unremarkable. Arthritis involving proximal interphalangeal joints and wrist joints was noticed. On chest auscultation, bilateral rhonchi and basal crepts were noted. Review of other systems was essentially normal. A complete blood count and liver and kidney function tests were ordered along with a chest radiograph, electrocardiogram (ECG), pulmonary function test, arterial blood gas, and an echocardiogram. Her chest X-ray was suggestive of chronic obstructive pulmonary disease with chronic bronchiectasis. The patient's forced vital capacity (FVC) was 28% predicted with reversibility of 24% and forced expiratory volume in 1 s (FEV1) was 31% predicted with 35% reversibility. The overall impression was that of severe airflow obstruction with overlapping restrictive pattern. Blood gas on 5 l oxygen by Hudson's face mask was as follows: pH: 7.483, pO2: 82.6, pCO2: 49.5, and HCO3: 36.4.
The patient was initially diagnosed to have a breast lump in 2009, a fine-needle aspiration cytology done subsequently clinched the diagnosis as IDC, and she was started on tamoxifen by her local physician. She was later started on oral chemotherapy in the form of capecitabine. This treatment was continued for 6 months. Owing to the lack of relief in symptoms and gradually increasing the size of the tumor, she was given external radiotherapy from September 2011 to October 2011. The patient could not tolerate more sessions of radiation therapy because of poor pulmonary reserve and bronchial asthma. She had been refused general anesthesia and surgery in four tertiary care setups because of her age and poor pulmonary status. Now, she had developed ulceration over the tumor with bleeding, and surgical management was the only available palliative/therapeutic intervention.
We discussed possible regional anesthetic options available with the surgical team and patients' attendants. After reviewing the literature and based on our own experience with regional techniques for breast surgery, we zeroed on using cervical epidural anesthesia for her surgery, as this is the only technique that can obviate the need for any general anesthetic and hence minimize the postoperative pulmonary complications and hasten the recovery.
The patient was fasted for 6 h prior to the surgery. Deriphyllin and nebulization with salbutamol and ipratropium bromide were given an hour before the surgery. The patient was counseled for the procedure and an informed consent was obtained. Once inside the operation theater, a 20G intravenous cannula was secured in the forearm on the nonoperative site. Standard monitors, i.e., ECG, SpO2, and noninvasive blood pressure, were applied. As the patient was apprehensive, we decided to start dexmedetomidine infusion before placing the epidural catheter. A loading dose of 1 mcg/kg was infused over 10 min. Under complete aseptic precautions, with the patient in sitting position, an 18G epidural catheter was threaded into the epidural space at C7–T1 interspace using 18G Tuohy's needle. Epidural space was identified at 4 cm depth from the skin using loss of resistance technique, and the catheter was threaded in cephalic direction and fixed at 8 cm mark at skin level. The catheter was secured to skin using a sterile transparent dressing. The patient was made to lie supine and a test dose of 2 ml bupivacaine 0.25% with 1:200,000 adrenaline was given after careful negative aspiration for blood and cerebrospinal fluid. Once intrathecal or intravascular placement had been ruled out, 5 ml of bupivacaine 0.25% was given. Dexmedetomidine maintenance infusion was started and maintained at 0.5 mcg/kg/h. A further 5 ml of lignocaine 2% with adrenaline 1:200,000 was given 10 min later through the epidural catheter. Level of analgesia was checked 10 min later and was found to be C5–T6. The surgery was started, and the patient tolerated the procedure well except for mild pain during axillary dissection which was managed with 3 ml epidural top-up of lignocaine 2%. The surgery lasted 1 h and 50 min. The SpO2 and end-tidal CO2 (ETCO2) were monitored and remained close to preblock values throughout the surgery. The patient's respiratory rate increased from 18 to 22 breaths/min, and the patient did not complain of any respiratory distress. No major hemodynamic changes were observed after giving the epidural local anesthetic. A total blood loss of 100 ml was estimated. The patient received 700 ml of lactated Ringer's solution. No colloid or blood product administration was required. After the completion of the surgery, dexmedetomidine infusion was discontinued and the patient was shifted to the postanesthesia care unit. The patient was awake, cooperative, and pain free in the recovery with no cough, nausea, or vomiting. She was again nebulized with salbutamol and Budecort. Two hours later, 5 ml of bupivacaine 0.125% was given through the cervical epidural catheter and the catheter was removed. Further postoperative pain was managed with intravenous tramadol and paracetamol.
| Discussion|| |
Regional analgesia has long been used as a supplement to general anesthesia for radical breast surgeries to reduce the adverse effects of general anesthesia and high doses of systemic opioids, namely postoperative respiratory depression, nausea, and vomiting, and delayed recovery from general anesthesia. The popular techniques used for regional nerve blocks include the thoracic paravertebral, intercostal, thoracic epidural, and the newly emerged “pecs” blocks. All these blocks are effective when the surgery does not involve the axillary and subclavicular regions which correspond to the T2 dermatome and C4 dermatome, respectively. Cervical epidural, employed at C7–T1 or C6–C7 level, is the only technique which can provide complete anesthesia of all the dermatomes involved in radical mastectomy. Another advantage of central neuraxial analgesia found in a study by Takeshima and Dohi was of reduced blood loss during surgery. They found a 33% reduction in total blood loss when cervical epidural anesthesia was employed along with “light” general anesthesia. Singh et al. in their study of 50 patients undergoing modified radical mastectomy found cervical epidural anesthesia as a safe alternative to general anesthesia with no respiratory complications.
The safety of cervical epidural anesthesia has been studied and well established in a large number of patients. In a study by Waldman, no neurological complications were documented in 790 patients who received cervical epidural injections and just two episodes of dural puncture which is comparable with the more commonly used lumbar and thoracic approaches. Another concern of phrenic nerve paralysis and resulting respiratory compromise has also been annulled by various studies. Michalek et al. in their evaluation of cervical epidural anesthesia for total parathyroidectomy in 15 patients noted only minimal changes in peak expiratory flow (PEF), maximal expiratory flow, and FEV1/FVC ratio, though FVC was decreased, but no patient complained of dyspnea during the procedure and in the postoperative period, and there were no episodes of fall in oxygen saturation at any point of time. Huang evaluated the effect of 12 ml of lignocaine 2% with 1:200,000 on respiratory function in ASA I and II patients. Inspiratory VC, VC, FVC, FEV1, and PEF were found decreased by 18% at 20 min and 12% at 50 min, and FEV1: FVC ratio was maintained within normal limits. Considering the fact that our patient had markedly reduced FEV1 and FVC, we gave the local anesthetic in small aliquots titrating to the desired level of block and monitoring her respiration and hemodynamic parameters. We did not encounter any significant reduction in respirator excursions; respiratory rate was only slightly increased from 18 to 22 breaths/min. The ETCO2 was maintained within normal limits before and after administration of block and remained so in the postoperative period also.
Dexmedetomidine has been used for providing conscious sedation in patients undergoing surgery in regional anesthesia as well as for procedural sedation and sedation in the intensive care unit. Paris and Tonner in their drug review concluded that dexmedetomidine offers beneficial pharmacological properties, providing dose-dependent sedation, analgesia, sympatholysis, and anxiolysis without relevant respiratory depression. Hence, we opted for using dexmedetomidine to provide conscious sedation in our patient.
| Conclusion|| |
Cervical epidural anesthesia, when employed carefully, can be useful in patients with preoperative respiratory compromise. It may improve postoperative outcome with reduction in respiratory complications and other adverse effects of general anesthesia. Dexmedetomidine is a useful adjunct to regional anesthesia when further respiratory depressant effects of other sedative drugs need to be avoided.
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.
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Conflicts of interest
There are no conflicts of interest.
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