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Editor-in-Chief : Mohamad Said Maani Takrouri (KSA)
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Anesthesia: Essays and Researches
Case Report
Giant cervical lipoma excision under cervical epidural anesthesia: A viable alternative to general anesthesia Ram Pal Singh, Aparna Shukla, Satyajeet Verma1 Departments of Anaesthesiology and Intensive Care, 1Surgery, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India Corresponding author: Dr. Ram Pal Singh, Assistant Professor, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh - 243 006, India. E-mail: [email protected]
Abstract The technique of Cervical Epidural Anesthesia (CEA) was first described by Dogliotti in 1933 for upper thoracic procedures. Administration of local anesthetic into cervical epidural space results in anesthesia of the neck, upper extremity, and upper thoracic region. CEA provides high-quality analgesia and anesthesia of above dermatomes and, at the same time, it has favorable effect on hemodynamic variable by blocking sympathetic innervation of the heart. CEA is not practiced routinely because of its potential complications. We selected this technique of CEA for excision of giant cervical lipoma on the back of the neck in an adult patient, as the patient was unwilling for general anesthesia. CEA was induced with 10 ml of 1% lignocaine-adrenaline mixture administered into C7-T1 space through 18G Tuohy needle. Our patient maintained vital parameters throught the procedure. The added advantage of epidural anesthesia was that the patient was awake and comfortable throughout the procedure. Key words: Cervical lipoma, epidural anesthesia, general anesthesia
INTRODUCTION The technique of Cervical Epidural Anesthesia (CEA) can be used successfully for procedures involving the neck and upper thorax. This technique is less commonly practiced due to the concern of potential complications such as dural puncture and paralysis of respiratory muscles. However, in the hands of an expert anesthesiologist, the risks associated with these complications are low. A number of prospective and retrospective studies have compared the frequency of both perioperative Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.94781
204
Quick Response Code
and postoperative complications of CEA. Results from some studies suggest that when CEA was used for procedures such as carotid endarterectomy, the morbidity and mortality rates were low and the hemodynamic variables better maintained.[1,2] This technique offers the advantage of better and early postoperative recovery and reduced incidence of postoperative cardio-respiratory complications. We successfully used technique of CEA for surgical excision of tumor on the back of neck.
CASE REPORT After obtaining a written informed consent, a 40- year- old American Society of Anaesthesiologists (ASA) grade I male patient was posted for surgical excision of giant cervical lipoma, on the back of neck, measuring 12 × 10 × 4.5 cm. On preanesthetic check-up, all routine investigation results were within normal limit. The patient was kept nil orally after 12 midnight prior to surgery. He was premedicated with tablet alprazolam 0.5 mg half an
Anesthesia: Essays and Researches; 5(2); Jul-Dec 2011 Singh, et al.: Giant cervical lipoma excision under cervical epidural anesthesia
hour before dinner and at 6 o’clock in the morning of surgery to allay anxiety.
and comfortable during the entire intraoperative and postoperative period [Figure 2].
On arrival to the operation theater, an intravenous line was secured with 18G cannula and Lactated Ringer’s solution was started. All anesthetic equipment were checked and monitors attached to the patient. Electrocardiogram (ECG), Oxygen Saturation (SpO2), Noninvasive Blood Pressure (NIBP), and Heart Rate (HR) were monitored continuously throughout the intraoperative period. The patient was premedicated with injection ondansetron 6 mg and was properly briefed prior to the procedure. CEA was performed with the patient in a sitting position. With all aseptic precautions, the neck was flexed to make the cervical vertebrae prominent. The C7-T1 space was infiltrated with 3 ml of 2% lignocaine with adrenaline to provide local anesthesia. Thereafter, a wide-bore needle was inserted at the C7-T1 level to create a passage for epidural needle. An 18G Tuohy needle was inserted in the epidural space, which was identified using the ‘hanging drop’ technique. An 18G epidural catheter was then inserted in the space up to the depth of 3 cm [Figure 1]. The direction of catheter tip was kept cephalad. The catheter was fixed in position. Correct placement of the catheter was verified by negative aspiration for blood and CSF, followed by administration of a test dose of 3 ml of 2% lignocaine with adrenaline. The patient was positioned supine on the operating table and vital parameters were monitored with 5-lead ECG, SPO2, NIBP, and HR. After about 5 minutes, 10 ml of 1% lignocaine with adrenaline with 1 mg of butorphanol injected via epidural catheter. After assessing the level of sensory block, the patient’s position was changed to prone. A soft pillow was kept under his chest to make the surgical area prominent and one head ring under the forehead to keep the head in a fixed position. Oxygen was given by nasal cannula at the rate of 2 L/min. All emergency equipment were kept ready to handle any emergency. The surgery lasted for one hour and intraoperative period was uneventful. The patient’s vitals were maintained during the intraoperative period [Table 1]. The patient was awake
No significant decrease was observed in systolic and diastolic blood pressure from the baseline values. Although there was a slight decrease in systolic blood pressure, diastolic blood pressure, and heart rate, none of the patients required therapeutic intervention. The lowest mean blood pressure was 82 mm Hg at 5 minutes and the lowest heart was 62/ min at 60 minutes, which was acceptable. Oxygen saturation remained in the range of 95-99%.
However, contradicting results were seen in the study of Domínguez et al.,[4] who reported three patients scheduled for shoulder surgery under CEA with 0.75% ropivacaine. They found that the extent of blockade to the upper thoracic sensory segments causes a total or partial sympathetic block with decreased HR, blood pressure, and cardiac output.
Figure 1: Cervical epidural catheter placement at the C7-T1 level
Figure 2: Patient sitting comfortably in postoperative ward
DISCUSSION The study found that CEA is a safe and effective alternative to general anesthesia during excision of tumors in the region of neck. Although we chose this technique due to the patient’s refusal to general anesthesia, our experience with this technique was encouraging. The patient not only remained awake and comfortable throughout the procedure, but also maintained vital parameters. There was no significant fall in systolic and diastolic blood pressure and heart rate so as to require therapeutic intervention. Our findings were comparable to those by Singhet al.,[3] who evaluated the safety and efficacy of CEA in 55 patients undergoing modified radical mastectomy. They found no clinically significant variations in per-operative pulse and respiratory rate; there was no fall in mean arterial blood pressure during the procedure. The authors concluded that CEA is a safe alternative to general anesthesia.
205
Anesthesia: Essays and Researches; 5(2); Jul-Dec 2011 Singh, et al.: Giant cervical lipoma excision under cervical epidural anesthesia
Table 1: Intraoperative vital parameters of the patient Time interval (minutes)
Heart rate (/minute)
Mean BP
Oxygen saturation SpO2 (%)
Baseline
80
122
67
85
97
5
75
115
66
82
97
10
81
129
75
93
97
15
76
119
74
89
97
20
76
116
69
85
97
25
72
114
68
83
96
30
70
117
71
86
97
35
72
114
70
85
97
40
69
116
72
86
99
45
68
118
70
86
94
50
67
116
87
96
97
55
63
116
86
96
98
60
62
118
86
97
97
Systolic
Bonnet et al.[5] reported carotid surgery under CEA in 394 patients by using 15 ml of 0.5 per cent bupivacaine or 0.37-0.40 per cent bupivacaine plus fentanyl (50-100 µg). They found an effective sensory blockade from C2 to T4T8. Patients were awake during the surgical procedure in comfortable condition. In their study, hypotension and bradycardia were the most frequent side effects of CEA. They concluded that carotid artery surgery may be performed under CEA, but hemodynamic variables should be monitored and managed closely during the procedure. In a retrospective study, Hakl et al.[6] compared the Cervical Plexus Block (CPB) and Cervical Epidural (CE) for carotid endarterectomy in 1,455 patients. They administered 20 ml drug consisting of 16 ml of bupivacaine 0.5% and 4 ml (20 μg) of sufentanil. They encountered 13 cases of accidental subarachnoid injection with CEA, but did not find any clinically significant respiratory distress. From our study and other documentary evidences, we conclude that CEA is a safe and effective alternative to general anesthesia for neck surgery. The advantage of this technique is that it provides all benefits of regional anesthesia. Although in our study we did not encounter any episode of significant bradycardia or hypotension,
206
NIBP (mm Hg) Diastolic
caution must be maintained while performing such block. We strongly recommend that the vitals of patients should be closely and continuously monitored throughout the intraoperative and postoperative period.
REFERENCES 1. 2. 3. 4. 5. 6.
Florani P, Sbarigia E, Speziale F, Antonini M, Fiorani B, Rizzo L, et al. General anaesthesia versus cervical block and peri-operative complications in carotid artery surgery. Eur J Vasc Endovasc Surg 1997;13:37-42. McCleary AJ, Maritati G, Gough MJ. Carotid endartectomy: Local or general anaesthesia? Eur J Vasc Endovasc Surg 2001;22:1-12. Singh AP, Tewari M, Singh DK, Shukla HS. Cervical epidural anesthesia: A safe alternative to general anesthesia for patients undergoing cancer Breast Surgery. World J Surg 2006;30:2043-7. Domínguez F, Laso T, TijeroT, Ruiz-Moyano J, Hernández J, Puig A. Cervical epidural anesthesia with 0.75% ropivacaine in shoulder surgery. Rev Esp Anestesiol Reanim 2002;49:39-43. Bonnet F, Derosier JP, Pluskwa F, Abhay K, Gaillard A. Cervical epidural anaesthesia for carotid artery surgery. Can J Anesth 1990;37:353-8. Hakl M, Michalek P, Sevcík P, Pavlíková J, Stern M. Regional anaesthesia for carotid endarterectomy. An audit over 10 years. Br J Anaesth 2007;99:415-20.
How to cite this article: Singh RP, Shukla A, Verma S. Giant cervical lipoma excision under cervical epidural anesthesia: A viable alternative to general anesthesia. Anesth Essays Res 2011;5:204-6. Source of Support: Nil, Conflict of Interest: None declared.
Copyright of Anesthesia: Essays & Researches is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editor-in-Chief : Mohamad Said Maani Takrouri (KSA)
Open Access HTML Format
For entire Editorial Board visit : http://www.aeronline.org/editorialboard.asp
Anesthesia: Essays and Researches
Case Report
Giant cervical lipoma excision under cervical epidural anesthesia: A viable alternative to general anesthesia Ram Pal Singh, Aparna Shukla, Satyajeet Verma1 Departments of Anaesthesiology and Intensive Care, 1Surgery, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India Corresponding author: Dr. Ram Pal Singh, Assistant Professor, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh - 243 006, India. E-mail: [email protected]
Abstract The technique of Cervical Epidural Anesthesia (CEA) was first described by Dogliotti in 1933 for upper thoracic procedures. Administration of local anesthetic into cervical epidural space results in anesthesia of the neck, upper extremity, and upper thoracic region. CEA provides high-quality analgesia and anesthesia of above dermatomes and, at the same time, it has favorable effect on hemodynamic variable by blocking sympathetic innervation of the heart. CEA is not practiced routinely because of its potential complications. We selected this technique of CEA for excision of giant cervical lipoma on the back of the neck in an adult patient, as the patient was unwilling for general anesthesia. CEA was induced with 10 ml of 1% lignocaine-adrenaline mixture administered into C7-T1 space through 18G Tuohy needle. Our patient maintained vital parameters throught the procedure. The added advantage of epidural anesthesia was that the patient was awake and comfortable throughout the procedure. Key words: Cervical lipoma, epidural anesthesia, general anesthesia
INTRODUCTION The technique of Cervical Epidural Anesthesia (CEA) can be used successfully for procedures involving the neck and upper thorax. This technique is less commonly practiced due to the concern of potential complications such as dural puncture and paralysis of respiratory muscles. However, in the hands of an expert anesthesiologist, the risks associated with these complications are low. A number of prospective and retrospective studies have compared the frequency of both perioperative Access this article online Website
DOI
www.aeronline.org
10.4103/0259-1162.94781
204
Quick Response Code
and postoperative complications of CEA. Results from some studies suggest that when CEA was used for procedures such as carotid endarterectomy, the morbidity and mortality rates were low and the hemodynamic variables better maintained.[1,2] This technique offers the advantage of better and early postoperative recovery and reduced incidence of postoperative cardio-respiratory complications. We successfully used technique of CEA for surgical excision of tumor on the back of neck.
CASE REPORT After obtaining a written informed consent, a 40- year- old American Society of Anaesthesiologists (ASA) grade I male patient was posted for surgical excision of giant cervical lipoma, on the back of neck, measuring 12 × 10 × 4.5 cm. On preanesthetic check-up, all routine investigation results were within normal limit. The patient was kept nil orally after 12 midnight prior to surgery. He was premedicated with tablet alprazolam 0.5 mg half an
Anesthesia: Essays and Researches; 5(2); Jul-Dec 2011 Singh, et al.: Giant cervical lipoma excision under cervical epidural anesthesia
hour before dinner and at 6 o’clock in the morning of surgery to allay anxiety.
and comfortable during the entire intraoperative and postoperative period [Figure 2].
On arrival to the operation theater, an intravenous line was secured with 18G cannula and Lactated Ringer’s solution was started. All anesthetic equipment were checked and monitors attached to the patient. Electrocardiogram (ECG), Oxygen Saturation (SpO2), Noninvasive Blood Pressure (NIBP), and Heart Rate (HR) were monitored continuously throughout the intraoperative period. The patient was premedicated with injection ondansetron 6 mg and was properly briefed prior to the procedure. CEA was performed with the patient in a sitting position. With all aseptic precautions, the neck was flexed to make the cervical vertebrae prominent. The C7-T1 space was infiltrated with 3 ml of 2% lignocaine with adrenaline to provide local anesthesia. Thereafter, a wide-bore needle was inserted at the C7-T1 level to create a passage for epidural needle. An 18G Tuohy needle was inserted in the epidural space, which was identified using the ‘hanging drop’ technique. An 18G epidural catheter was then inserted in the space up to the depth of 3 cm [Figure 1]. The direction of catheter tip was kept cephalad. The catheter was fixed in position. Correct placement of the catheter was verified by negative aspiration for blood and CSF, followed by administration of a test dose of 3 ml of 2% lignocaine with adrenaline. The patient was positioned supine on the operating table and vital parameters were monitored with 5-lead ECG, SPO2, NIBP, and HR. After about 5 minutes, 10 ml of 1% lignocaine with adrenaline with 1 mg of butorphanol injected via epidural catheter. After assessing the level of sensory block, the patient’s position was changed to prone. A soft pillow was kept under his chest to make the surgical area prominent and one head ring under the forehead to keep the head in a fixed position. Oxygen was given by nasal cannula at the rate of 2 L/min. All emergency equipment were kept ready to handle any emergency. The surgery lasted for one hour and intraoperative period was uneventful. The patient’s vitals were maintained during the intraoperative period [Table 1]. The patient was awake
No significant decrease was observed in systolic and diastolic blood pressure from the baseline values. Although there was a slight decrease in systolic blood pressure, diastolic blood pressure, and heart rate, none of the patients required therapeutic intervention. The lowest mean blood pressure was 82 mm Hg at 5 minutes and the lowest heart was 62/ min at 60 minutes, which was acceptable. Oxygen saturation remained in the range of 95-99%.
However, contradicting results were seen in the study of Domínguez et al.,[4] who reported three patients scheduled for shoulder surgery under CEA with 0.75% ropivacaine. They found that the extent of blockade to the upper thoracic sensory segments causes a total or partial sympathetic block with decreased HR, blood pressure, and cardiac output.
Figure 1: Cervical epidural catheter placement at the C7-T1 level
Figure 2: Patient sitting comfortably in postoperative ward
DISCUSSION The study found that CEA is a safe and effective alternative to general anesthesia during excision of tumors in the region of neck. Although we chose this technique due to the patient’s refusal to general anesthesia, our experience with this technique was encouraging. The patient not only remained awake and comfortable throughout the procedure, but also maintained vital parameters. There was no significant fall in systolic and diastolic blood pressure and heart rate so as to require therapeutic intervention. Our findings were comparable to those by Singhet al.,[3] who evaluated the safety and efficacy of CEA in 55 patients undergoing modified radical mastectomy. They found no clinically significant variations in per-operative pulse and respiratory rate; there was no fall in mean arterial blood pressure during the procedure. The authors concluded that CEA is a safe alternative to general anesthesia.
205
Anesthesia: Essays and Researches; 5(2); Jul-Dec 2011 Singh, et al.: Giant cervical lipoma excision under cervical epidural anesthesia
Table 1: Intraoperative vital parameters of the patient Time interval (minutes)
Heart rate (/minute)
Mean BP
Oxygen saturation SpO2 (%)
Baseline
80
122
67
85
97
5
75
115
66
82
97
10
81
129
75
93
97
15
76
119
74
89
97
20
76
116
69
85
97
25
72
114
68
83
96
30
70
117
71
86
97
35
72
114
70
85
97
40
69
116
72
86
99
45
68
118
70
86
94
50
67
116
87
96
97
55
63
116
86
96
98
60
62
118
86
97
97
Systolic
Bonnet et al.[5] reported carotid surgery under CEA in 394 patients by using 15 ml of 0.5 per cent bupivacaine or 0.37-0.40 per cent bupivacaine plus fentanyl (50-100 µg). They found an effective sensory blockade from C2 to T4T8. Patients were awake during the surgical procedure in comfortable condition. In their study, hypotension and bradycardia were the most frequent side effects of CEA. They concluded that carotid artery surgery may be performed under CEA, but hemodynamic variables should be monitored and managed closely during the procedure. In a retrospective study, Hakl et al.[6] compared the Cervical Plexus Block (CPB) and Cervical Epidural (CE) for carotid endarterectomy in 1,455 patients. They administered 20 ml drug consisting of 16 ml of bupivacaine 0.5% and 4 ml (20 μg) of sufentanil. They encountered 13 cases of accidental subarachnoid injection with CEA, but did not find any clinically significant respiratory distress. From our study and other documentary evidences, we conclude that CEA is a safe and effective alternative to general anesthesia for neck surgery. The advantage of this technique is that it provides all benefits of regional anesthesia. Although in our study we did not encounter any episode of significant bradycardia or hypotension,
206
NIBP (mm Hg) Diastolic
caution must be maintained while performing such block. We strongly recommend that the vitals of patients should be closely and continuously monitored throughout the intraoperative and postoperative period.
REFERENCES 1. 2. 3. 4. 5. 6.
Florani P, Sbarigia E, Speziale F, Antonini M, Fiorani B, Rizzo L, et al. General anaesthesia versus cervical block and peri-operative complications in carotid artery surgery. Eur J Vasc Endovasc Surg 1997;13:37-42. McCleary AJ, Maritati G, Gough MJ. Carotid endartectomy: Local or general anaesthesia? Eur J Vasc Endovasc Surg 2001;22:1-12. Singh AP, Tewari M, Singh DK, Shukla HS. Cervical epidural anesthesia: A safe alternative to general anesthesia for patients undergoing cancer Breast Surgery. World J Surg 2006;30:2043-7. Domínguez F, Laso T, TijeroT, Ruiz-Moyano J, Hernández J, Puig A. Cervical epidural anesthesia with 0.75% ropivacaine in shoulder surgery. Rev Esp Anestesiol Reanim 2002;49:39-43. Bonnet F, Derosier JP, Pluskwa F, Abhay K, Gaillard A. Cervical epidural anaesthesia for carotid artery surgery. Can J Anesth 1990;37:353-8. Hakl M, Michalek P, Sevcík P, Pavlíková J, Stern M. Regional anaesthesia for carotid endarterectomy. An audit over 10 years. Br J Anaesth 2007;99:415-20.
How to cite this article: Singh RP, Shukla A, Verma S. Giant cervical lipoma excision under cervical epidural anesthesia: A viable alternative to general anesthesia. Anesth Essays Res 2011;5:204-6. Source of Support: Nil, Conflict of Interest: None declared.
Copyright of Anesthesia: Essays & Researches is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
