Saudi Journal of Anaesthesia

LETTER TO EDITOR
Year
: 2011  |  Volume : 5  |  Issue : 2  |  Page : 234--235

Continuous thoracic epidural analgesia for pain management in achondroplastic patient undergoing unilateral nephrectomy


Amit Jain1, Hemant Bhagat2, Jeetinder Kaur Makkar2, Kishore Mangal2,  
1 Department of Anaesthesia and Intensive Care, Alchemist Hospitals Ltd., Panchkula, Haryana, India
2 Post Graduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Amit Jain
Department of Anaesthesia and Intensive Care,Alchemist Hospitals Ltd., Panchkula, Haryana
India




How to cite this article:
Jain A, Bhagat H, Makkar JK, Mangal K. Continuous thoracic epidural analgesia for pain management in achondroplastic patient undergoing unilateral nephrectomy.Saudi J Anaesth 2011;5:234-235


How to cite this URL:
Jain A, Bhagat H, Makkar JK, Mangal K. Continuous thoracic epidural analgesia for pain management in achondroplastic patient undergoing unilateral nephrectomy. Saudi J Anaesth [serial online] 2011 [cited 2020 Oct 29 ];5:234-235
Available from: https://www.saudija.org/text.asp?2011/5/2/234/82820


Full Text

Sir,

There are few reports of the use of epidural analgesia in achondroplastic patients. Most of them have used lumbar epidurals in achondroplastic patients as a sole anesthetic technique [1],[2] or combined spinal-epidural technique. [3] We describe the use of thoracic epidural analgesia combined with general anesthesia in the management of an achondroplastic dwarf. Further, we successfully used continous epidural analgesia for postoperative pain management in an achondroplastic patient following major upper abdominal surgery.

A 56-year-old achondroplastic female with unilateral non-functioning kidney was scheduled to undergo elective unilateral nephrectomy. She was 106 cm tall with a weight of 30 kg. She had short limbs with trunk of relatively normal length, protuberant head, saddle nose, pectus excavatum and thoracolumbar kyphoscoliosis. Airway examination revealed a very large tongue with high-arched palate. She was Mallampati class III with normal neck movements. Mentohyoid and mentothyroid distances were unremarkable. Her complete hemogram and blood biochemistry profile were normal. Her pulmonary function tests showed moderate restrictive pattern. The potential risks and benefits of general and regional anesthesia were explained to the patient. She consented to general anesthesia with epidural analgesia. In the operating room, standard anesthesia monitoring was applied and a 16-gauge intravenous cannula was secured in left upper limb. A 20-gauge epidural catheter was sited at D9-10 interspace. Following the administration of test dose and confirming the catheter location, 4 ml of 0.25% bupivacaine was injected via the catheter in 2 ml increments at three-min intervals to attain loss of sensation to pin-prick up to D6 dermatome. Additional 50 μg fentanyl was administered just before induction. Anesthesia was induced with propofol 60 mg and morphine 4.5 mg. Vecuronium 4 mg was given to facilitate tracheal intubation with size 6.0 cuffed tracheal tube and the lungs were mechanically ventilated. Anesthesia was maintained with propofol infusion along with nitrous oxide in oxygen (70:30). Patient was then placed to the left lateral position. Second epidural bolus (4 ml of 0.25% bupivacaine) was administered after 90 min and third epidural bolus (4 ml of 0.125% bupivacaine) before the surgical closure. The surgery was uneventful and the trachea was extubated after regaining consciousness and adequate reversal of neuromuscular blockade. Patient was pain free on extubation. Postoperatively, analgesia was provided with continuous epidural infusion of bupivacaine 0.125% at the rate of 4 mlh-1, for 48 h. Patient did not complain of any pain or side effects. The epidural catheter was removed on the third postoperative day and the patient was subsequently discharged on the 8 th postoperative day.

Regional anesthesia in achondroplastics could be complicated by the presence of one or more of the following: Kyphosis, scoliosis, lumbar lordosis, spinal stenosis, osteophytes, short pedicles, or a small epidural space. [2] These could lead to difficulties in locating the epidural space with increased risk of dural puncture, patchy blocks and spinal cord trauma. [2],[4] This, combined with the lack of dosage guidelines, has led to the reluctance of clinicians to use regional blockade in cases of achondroplasia. Our decision to put thoracic epidural in the present case was based on two facts. First, the abnormalities observed in achondroplastic patients are similar to the degenerative changes seen in the elderly, a population in which regional techniques are frequently used. Second, catheter-insertion congruent analgesia resulted in optimal postoperative epidural analgesia by infusing analgesic agents to the appropriate incisional dermatomes, providing superior analgesia, minimizing side effects and decreasing morbidity. [5] Further, the benefits of epidural analgesia in decreasing morbidity in patients undergoing abdominal surgery are seen only with thoracic (congruent), not lumbar (incongruent), epidural catheter placement. [6]

In achondroplastic patients, respiratory functions may be impaired by several factors specific to achondroplasia.[1] Major abdominal surgery in these patients may further increase the risk of complications and thereby the need for postoperative mechanical ventilation. However, adequate analgesia in the postoperative period could safeguard against pain-associated diaphragmatic splinting and poor respiratory efforts, resulting in early and effective participation of the patient in pulmonary physiotherapy. Thus, we described the successful use of thoracic epidural technique for the intraoperative pain management as well as continous postoperative analgesia in an achondroplastic patient following unilateral nephrectomy under general anesthesia. We suggest that the achondroplastic patients, especially those undergoing major abdominal surgery, should not be denied the benefits of epidural anesthesia in the absence of evidence that it is unreliable or unsafe.

References

1Morrow MJ, Black JH. Epidural anaesthesia for caesarean section in an achondroplastic dwarf. Br J Anaesth 1998;81:619-21.
2Carstoniu J, Yee I, Halpern S. Epidural anaesthesia for cesarean section in an achondroplastic dwarf. Can J Anaesth 1992;39:708-11.
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4Di Nardo SK. Anesthetic considerations for the achondroplastic dwarf. AANA J 1988;56:42-8.
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