Authors: Çağla Yazar1*, Nedim Çekmen2
1 MD Anesthesiology
2 MD, PhD, Anesthesiology
Department of Anesthesiology, Başkent University, Ankara, Turkey
*Correspondence: Fevzi Cakmak Cad. 10. Sok No: 45, Çankaya, Ankara 06490, Turkey, tel: +90-545 416 07 79, e-mail:
Thoracic epidural anaesthesia (TEA) is frequently used for anaesthesia and analgesia in today’s practice. Although cholecystectomy is a surgical procedure performed under general anaesthesia (GA), many studies in recent years have shown that neuraxial techniques can be used safely. We aimed to present the anaesthesia management under dexmedetomidine sedation with TEA in high-risk patients who underwent laparoscopic cholecystectomy surgeries. Both patients were of geriatric age and had several comorbidities. In patients, we preferred TEA to avoid the cardiorespiratory effects of GA. Preoperative preparation of patients with a multidisciplinary approach, cooperation, and close follow-up is essential in preventing complications.
Glossary of Terms: Thoracic epidural anaesthesia (TEA), general anaesthesia (GA), thoracic epidural (TE), body mass index (BMI), electrocardiogram (ECG), transthoracic echocardiography (TTE), ejection fraction (EF), tricuspid annular plane systolic excursion (TAPSE), intravenous (IV), patient-controlled analgesia (PCA), intensive care unit (ICU).
In today’s anaesthesia practice, thoracic epidural (TE) methods are frequently used for intraoperative anaesthesia and postoperative analgesia. Although cholecystectomy is a sur-gical procedure traditionally performed under general anaesthesia (GA), many studies in re-cent years have shown that neuraxial techni-ques can be used safely, especially in patients with significant cardiorespiratory dysfun-ction1,2. GA together impairs mucociliary activity, reduces functional residual capacity, and negatively affects respiratory functions. Thoracic epidural anaesthesia (TEA) provides a more stable hemodynamic management than GA and protects the patient from the harmful effects of positive pressure ventilation; it effe-ctively reduces postoperative pain and ambu-lates patients as early as possible3. In these cases, we aimed to present the anaesthesia ma-nagement under dexmedetomidine sedation with TEA in high-risk patients who underwent open and laparoscopic cholecystectomy surge-ries.
1. Case 1
An 89-year-old male (70 kg, 170 cm, body mass index (BMI) 24,2 kg/m2) had a history of chronic pulmonary thromboembolism, deme-ntia, and prostate cancer. The patient was on antihypertensive and anticoagulant therapy. The anticoagulant medication was stopped 3 days before surgery. His presented laboratory parameters were within the normal range. An electrocardiogram (ECG) showed a normal si-nus rhythm of 75/min and 1st degree atrioven-tricular block. In the transthoracic echocardio-graphy (TTE), ejection fraction (EF) of 57 %, tricuspid annular plane systolic excursion (TAPSE) 18, and left ventricular diastolic dys-function was detected. Bilateral atelectasis and minimally pleural effusion in computer tomo-graphy were detected. He had effort dyspnea during the preoperative period. The patient was evaluated by effort capacity class III and mal-lampati score III. Together with all the comor-bidities patient was evaluated with an ASA III score.
After standard monitorization, heart rate was 84/min, blood pressure was 143/65 mmHg, and SpO2 was 95. An 18 G intravenous (IV) access was provided, and after that, the patient was premedicated with midazolam® and fenta-nyl®. The epidural space (T5-T6) was identifi-ed with the patient in a sitting position using a midline approach and the loss-of-resistance technique. The epidural catheter was inserted approximately 4 to 5 cm into the epidural spa-ce (Figure 1).
The patient received a pre-induction TE injection of 0.5 % bupivacaine® (125 mg) after the adrenaline test (50 µg). Deep sedation was given with dexmedetomidine infusion.
The sensory and motor block were assessed using a pinprick test and the Bromage scale, respectively. When the level of sensory block reached T4, the Bromage scale was 0, and the operation was initiated 20 min after the epidural bolus dose. The patient tolerated the incision well, and nasal oxygen was given to the patient during the surgery. After 26 min of incision, surgery returned to the open cholecy-stectomy because of adhesive and fibrotic sac (Figure 2).
The patient received a dexmedothymidine® IV infusion during the surgery, which lasted 115 minutes. The Infusion dose range was titrated according to hemodynamic changes and the Ramsey sedation scale. After the patient was kept in the recovery room, he was discharged to the ward with 0.1% epidural bupivacaine® patient-controlled analgesia (PCA). He was mobilized after the Bromage score was 4 at the postoperative 6th hour. The epidural catheter was removed the following day. The postoperative period was uneventful, and 2 days later, the patient was discharged home.
2. Case 2
A 72-year-old male (105kg, 175 cm, BMI 34,2 kg/m2), who had a history of coronary artery disease, atrial fibrillation (AF), heart failure with low EF, operated prostate cancer, epile-psy, bilateral stenosis of the internal carotid artery and occlusion in the left vertebral artery. The patient was on antihypertensive, anti-coagulant, diuretic, antiepileptic, and beta-blocker therapy. The anticoagulant medication was stopped 3 days before surgery. An ECG showed AF of 77/min. In the TTE EF of 23 %, TAPSE 11 global hypokinesia and 2nd-degree tricuspid regurgitation were detected. After preoperative coronary angiography was perfor-med on the patient whom the cardiologist evaluated, the operation was assessed as high risk because of occlusions in the coronary arte-ries. Furthermore, postoperative ICD insertion was recommended.
He suffered from several comorbidities and had effort dyspnea, limited effort capacity, and cooperation-orientation during the preoperative period. The patient was evaluated by effort ca-pacity class III and mallampaty score II. Together with all the comorbidities patient was evaluated with an ASA IV score.
An 18 G IV access and left radial artery cannu-lation was provided; after that, the patient was premedicated with pheniramine®.
The patient was placed in a sitting position, and the TE catheter was inserted at the T 4-5 intervertebral space under aseptic conditions like case 1 (Figure 1). Bupivacaine 0.5% 25mL injected through the catheter with sensory loss up to T4 dermatome. Dexmedetomidine infusi-on was titrated to provide bispectral index va-lues between 40- and 60 for deep sedation. In the intraoperative period, the patient was desa-turated and ventilated with positive pressure by inserting the airway for 5 minutes, and the dex-medetomidine infusion dose was reduced. Throughout the operation, Bromage score was 1, and Ramsey’s sedation score was 6. At the end of the operation, the patient opened his eyes to tactile and painful stimuli and made meaningless sounds, but he was inclined to sleep, and his SpO2 was between 86-92%. He was transferred to the intensive care unit (ICU) for further examination and close follow-up. His Glasgow coma score was (GCS) 10, and his Apache II score was 19 when he was ad-mitted to the intensive care unit. Since there was no increase in GCS, diffusion MRI was performed, and acute infarction was observed in the right posteroparietal and temporoocci-pital regions. Pulmonary CT angiography reve-aled a thrombus in the right atrium. The patient, whose general condition improved after the treatment, was discharged from the ICU on the second postoperative day and from the service on the fourth postoperative day.
The laparoscopic cholecystectomy procedure has become the standard method for treating gallbladder stones because It is less invasive and allows shorter hospital stays, and early ambulation, thus reducing hospital costs. Its adverse effects are mainly related to inflation of the peritoneal cavity, the use of CO2, and postural changes. Pneumoperitoneum affects hemodynamic parameters because of an incre-ase in systemic vascular resistance and pain due to stretch, leading to intraoperative tachy-cardia and hypertension1. If the intra-abdo-minal pressure is > 15 mmHg, venous return is reduced due to compression of the inferior vena cava, and hypotension is observed. There-fore, we adjusted the maximum value of intra-abdominal pressure to 12 mmHg in our limited cardiac reserve patient. GA with endotracheal intubation is the most preferred method for la-paroscopic cholecystectomy surgery. It facili-tates intra-abdominal surgery by providing mu-scle relaxity and the opportunity to manage hy-percarbia due to carbon dioxide pneumoperito-neum1,2. Besides all these, GA has recently started to be replaced by epidural anaesthesia (EA) because it is associated with significant postoperative complications such as pain, nau-sea/vomiting, airway trauma, and pressor re-sponses to intubation/extubation and due to pneumoperitoneum, increases myocardial oxy-gen consumption due to sudden hemodynamic changes, impaired intracerebral perfusion, wor-se pain control, and neuroendocrine response compared to neuraxial methods2,3. EA enables stable hemodynamic and respiratory manage-ment in the intraoperative period; It also ena-bles early discharge from the hospital, prima-rily by reducing opioid use in elderly patients, reducing the incidence of postoperative deliri-um, and enabling early mobilization and rapid return of bowel movements. Geriatric patients have high morbidity and mortality due to reduced physiological capacities, comorbidi-ties, multiple drug use, cognitive dysfunction, and increased frailty4. Comorbid diseases can also be seen frequently in these patients, so all factors should be considered when choosing the anaesthesia method. Our patients were ge-riatric, high-risk ASA III and IV patients with several comorbidities. In the light of the litera-ture, we planned to combine TEA with dex-medetomidine infusion to protect our patients from the harmful effects of general anaesthe-sia. TEA is not considered a safe technique. The two main concerns are a greater risk of damaging the spinal cord with the needle du-ring the dura puncture and ventilatory impair-ment caused by an extensive thoracic nerve block. During follow-up, we did not observe a-ny ventilatory complications, hypotension, or bradycardia in our patients.
Dexmedetomidine® is a selective α2-adrener-gic receptor agonist, sedative, anxiolytic, sym-patholytic, and analgesic agent. It also has a neuroprotective role, especially in elderly pati-ents. Hun et al. showed that dexmedetomi-dine® was effective on postoperative delirium and emergence agitation in elderly patients. They associated this with a stable hemodyna-mic profile and a decrease in IL-6, a pro-in-flammatory agent5. We preferred dexmedeto-midine® in both cases and we had to adjust the dose due to bradycardia, Ramsey sedation sca-le, and BIS values in our patients.
In conclusion, TEA is a technique that can be used safely compared to general anesthesia wi-th careful patient selection in abdominal surge-ries. Preoperative comprehensive preparation of the patient with a multidisciplinary appro-ach, preparation for resuscitation, cooperation with the surgery team, and close postoperative follow-up are very important in preventing complications.
Addittional materials: No
YÇ collected paper’s data, drafted the paper and is the lead author. ÇN contributed to planning and the critical revision of the paper.
Availability of supporting data:
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
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No IRB approval required.
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Patients consents were obtained
Competing interests: The authors declare that they have no competing interests.
Received: August 2022, Accepted: August 2022, Published: September 2022.
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|Citation: Çağla Yazar, Nedim Çekmen. Cholecystectomy management under dexmedetomidine sedation with thoracic epidural anesthesia in two high-risk geriatric patients: Case reports and literature review. Greek e j Perioper Med. 2022;21 (b): 55-61.|
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