Abstract ID: A15
Abstract Title: CONTINUOUS EPIDURAL ANAESTHESIA IN QUADRIPLEGIC PATIENTS UNDERGOING LOWER ABDOMINAL SURGERY.
Authors: Wiessner D1, Groessle R2, Hakenberg O3, Litz R4
University Hospital Dresden Dresden Saxony Germany1, University Hospital Dresden Dresden Saxony Germany2, University Hospital Dresden Dresden Saxony Germany3, University Hospital Dresden Dresden Saxony Germany4
Poster Type: Either
ABSTRACT BODY
Introduction:Quadriplegic patients with high thoracic or cervical spinal cord lesions may suffer from secondary effects of their illness, e.g. obstipation. Additionally, due to urethral sphincter- and detrusor dyscoordination high intravesical pressures may lead to an impairement or even loss of renal function. Mitrofanoff’s principle-MP (appendicovesicostomy) enables such patients to perform clean self-catheterisation (CIC), thus giving them control of bladder function. However, although these patients do not experience somatic pain during surgery, autonomic hyperreflexia (AH) triggered by bladder distension or surgical stimulus may occur in up to 85 %. This may result in severe complications and even fatal outcome. In paraplegic pregnant patients control of AH was successfully achieved with sympathetic block by means of epidural analgesia (EA). We report our experience with a care pathway in 13 consecutive paraplegic patients undergoing MP.
Materials and Methods:All patients were offered EA for intra- and postoperative pain control as well as sympathicolysis. Epidural catheters were placed at thoracic interspace 8-10 using the loss of resistance to saline technique. 10-15 ml of ropivacaine 0.2% and sufentanil 0.5µg/ml were applicated. Postoperative epidural application was continued at a rate of 6-10 ml/h until hemodynamic control was possible without application of vasoactive drugs and regular gastrointestinal function (GIF) including full oral nutrition was restored. Oral intake of a regular diet was allowed if bowel sounds were present. Mobilisation and physiotherapy were started on the first postoperative day (POD) if possible. Perioperative data concerning the care program were sampled online by a computed database and analysed for perioperative complications with special regard to hemodynamic, respiratory and GI-function.
Results:Within a 7-year period 13 quadriplegic patients (10 female; 3 male; 33±12 years; 65±12kg) underwent MP (8 patients with low cervical lesions (C4-6), 5 with high thoracic lesions). 2 patients refused epidural analgesia and were excluded. EA was provided for 2-5 days. In all patients GIF was restored by the 4th POD (2.9±0.8d) and regular oral diet was tolerated within 2.3±1.0d without nausea or vomiting. No patient showed hypertension or tachycardia in the perioperative course, as defined as an increase in systolic blood pressure or heart rate of more than 30% to baseline (Fig. 1 and 2). None of the patients suffered from respiratory depression or AH. In all patients mobilisation could be started within two PODs. With the exception of one patient who underwent relaparotomy for mechanical ileus no complications occurred in the postoperative course.
Discussion:These results from a retrospective analysis of a case series of 11 patients only indicate that continuous EA may be used for intra-and postoperative analgesia as well as sympathicolysis in paraplegic patients undergoing lower abdominal surgery. With this regimen, potentially life threatening complications like AH or postoperative ileus may be successfully limited. Therefore, continuous EA should be considered as an element in a collaborate perioperative care pathway in paraplegic patients allowing early oral feeding and mobilisation.
ATTACHED FILES
Reg Anesth Pain Med 2005; 30(3):A15