Regional anaesthesia for radical cystectomy and ileal conduit surgery with two epidural catheters.

Introduction: A patient with severe chronic obstructive lung disease diagnosed to have a bladder carcinoma and a radical cystectomy with ileal conduit surgery was planned. We report the perioperative anaesthetic management for this surgical procedure.

Case report: A 73 yr old man , chronic smoker for more than 30 years, presented with bladder carcinoma for which a radical cystectomy with ileal conduit surgery was planned by the urologists team. On assessing the patient preopearatively, it was found that the patient had severe chronic obstructive lung disease and mild pulmonary artery hypertension and no other comorbidities. Blood investigations were normal. ECG showed right bundle branch block and echocardiogram showed normal LV function with mild pulmonary artery hypertension. Chest X ray had emphysematous changes and pulmonary function test proved severe obstructive pattern. As regional anaesthesia has many advantages over general in this particular case , combined epidural spinal anaesthesia was planned. A need for the blockade of thoracic segments for bowel handling and also lumbosacral segments for pelvic dissection necessitated two epidural catheters placement. After securing intravenous access, under sterile precautions, T11 – T12 interspace identified, epidural space identified by LOR technique and catheter threaded cephaloid ( tip probably at T8 space). Soon, another epidural catheterisation done through L2 – L3 interspace , this time catheter threaded caudally ( tip probably at L5 space). Subarachnoid puncture done using paramedian approach through L3 L4 space and 12.5mg of 0.5% bupivacaine administered. Right sided internal jugular vein catheterisation done under USG guidance to monitor central venous pressure.

Thirty minutes after the start of surgery, thoracic epidural was activated with 10 ml of 2% lignocaine with adrenaline and topping up was done every 60 minutes. Two hours later lumbar epidural was activated with 8 ml of 0.5% bupivacaine. Surgery lasted for four hours. Patient was administered a continuous infusion of injection ketamine 20mg/hr intravenously for sedation as opioids and benzodiazepines were not preferred for their respiratory depressant effects.

Patient remained comfortable throughout the procedure. His ECG, NIPB, spo2, Respiratory rate, CVP were monitored continuously. Few intermittent doses of phenylephrine were given to treat hypotension caused by regional anaesthesia. A continuous infusion of 0.1% ropivacaine given through lumbar catheter at a rate of 7 ml/hr for post operative analgesia. Patient was observed in surgical intensive care unit for 48 hours post operatively. An immediate post op ABG was normal.

Discussion: A combined epidural and general anaesthetic technique is usually performed for radical cystectomy with ileal conduit procedures. General anaesthesia is considered to provide excellent comfort to both the patient and surgeon as the duration of the surgery is usually more. For such cases where general anaesthesia with endotracheal intubation may carry more risk due to obstructive lung diseases, regional anaesthesia would be an excellent choice. Two epidural catheters were inserted in this patient to provide a complete surgical anaesthesia below the level of T4. A very low dose of ketamine was selected for infusion intravenously as ketamine doesn’t depress respiration and is a bronchodilator as well.

Conclusion: Regional anaesthesia can be effectively and safely performed for radical cystectomy with ileal conduit procedures.

DR.V.MURALI MAGESH
CONSULTANT ANAESTHESIOLOGIST KAUVERY HOSPITAL
CHENNAI

Discussion:

A.
Dear Dr.Murali
This case presentation sent by you is an effort which needs appreciation, albeit it may raise a few questions.
1.How severe was the COPD? what was the effort tolerance of this patient?
2.What was the pre-op PaCO2 value?
3.while 2 effecticve epidural catheters were successfully placed to cover large segments of spinal cord to tolerate the surgery what was the need for subarachnoid block through different space?
If these points are clarified it is worth including in the case discussion segment.
Prof.Dr.Nagaswamy
Editor-in-Chief

B.
Good morning sir,

1. A case of COPD, moderate to severe, couldn’t optimize to the fullest, had incentive spirometry , steroids and nebulisation prior to surgery. His effort tolerance less than 4 METS , tachypnoeic at rest (Resp rate 25 / min)
Pre op pco2 was 46mmHg pao2 69mmHg, pH 7.34 in room air)

2. Sir, I used subarachnoid block also , for two reasons:
1. Mainly to come down on local anaesthetic volume and hence dose to avoid toxicity.
2. Immediate onset with better relaxation than epidural.

Dr.Murali Mahesh.

C.
Dear Dr.Vikram / Dr.Murali,
The points provided by Dr.Murali in his reply can be included in the text and published.
Thanks and once again congrats to Dr.Murali for safe management of a very complicated and high risk patient.
Keep it up.

Prof.Dr.Nagaswamy
Editor-in-Chief.