INTRODUCTION

Laparoscopy is generally performed under general anesthesia but regional anesthesia such as lumbar and thoracic spinal anesthesia has been widely used and has been found to be useful. In this case report, we write a case report that used thoracic spinal anesthesia (TSA) in pediatric patients who were classified as healthy patients. We performed the TSA action on the T10-T11 interspace. Bupivacaine, levobupivacaine, has been widely used as a local anesthetic in regional anesthesia. In addition, fentanyl, Dexmedetomidine and Ketamine as intrathecal adjuvants are used to accelerate the onset of action, increase the duration of analgesia, and reduce hemodynamic side effects during anesthesia due to the use of large local anesthetics.

METHOD

This was a retrospective case report, after analysis of patient clinical data. The patient provided written informed consent to publish their case details and any accompanying images. The study protocol complies with the requirements of the institute’s committee of Dr. H. Abdul Moeloek Hospital, Provinsi Lampung, Indonesia.

RESULTS

A 13-year-old female, American Society of Anesthesiologists physical status I scheduled for laparoscopic cholecystectomy. Investigations were done and informed written consent was taken. The patient was asked to remain nil per oral 6 h before surgery. Patient was preloaded with 500 ml lactated Ringer's solution. In operation theater, a good intravenous (IV) access 18 G was secured for preloading and a non-invasive monitor was attached for monitoring such as electrocardiogram, heart rate (HR), noninvasive blood pressure, oxygen saturation (SpO2), temperature, and respiratory rate. Sitting position for TSA and paramedian approach was used. TSA was given using 1 ml hyperbaric bupivacaine 5 mg/ml mixed with 0.5 ml of fentanyl 50 μg/ml, ketamine10 mg, dexmedetomidine 10 μg mixed in one syringe injected at T10-11 interspace with a 26-gauge spinal needle after confirming its placement by free flow of clear cerebrospinal fluid (figure 2). Finally, the patient was turned to the supine horizontal position for the operation, and oxygen nasal cannula was started at 2 L/min. Onset of action and level of sensory block was judged by thermal, pin prick method every minute until the establishment of desired block. Hypotension was defined as systolic blood pressure <90 mmHg or >20% decrease in baseline values and was treated by fluids and vasopressors (ephedrine 5 mg). Bradycardia was defined as HR <50/min and was treated by 0.5 mg of atropine intravenous. HR, blood pressure, and SpO2 were recorded every 3 min. Intra- and post-operative complications such as nausea, vomiting, pain, pruritus, headache, or any other side effects were recorded.

Figure 1. Administering spinal anesthesia in T10-T11 interspace

OBSERVATION

Sitting position, shoulder relaxed and TSA performed. Onset of sensory block T4-L2 required for minimally invasive laparoscopic cholecystectomy was achieved in 3 min and duration of block was 3 h. Surgery commenced using carbon dioxide insufflation and a pressure limit of 10–12 mmHg. Patient was sedated without intravenous sedation, Ramsay score achieved 3/6. There was single used of 5 mg ephedrine IV for hypotension and easy to threat and no need atropine during the surgery and the patient was hemodynamically stable during intraoperative and postoperative period (figure 2). Furthermore, SpO2 was above 95% at during laparoscope. Specific enquiry was made about postural puncture headache (PDPH) which was not experienced by our patient. Patient was followed for 72 h postoperatively and no complications were reported. Patient was no complain about neurological deficit postoperatively.

Figure 2. Monitor and situation during operation

DISCUSSION

TSA action is very easy to perform in the thoracic interspace 10-11 (T10-T11).[1] TSA can be performed as a single shot, continuous with special catheter or a combination with an epidural. The sitting position makes it easy to perform the TSA procedure because this position provides sufficient space for the needle to enter the subarachnoid space in the thoracic region.[2-5] Ultrasound is now routinely used to determine the correct thoracic level and it is strongly recommended.[6,7] Even using ultrasound in addition to the injection level, the depth of the needle can also be monitored so that spinal cord injury does not occur. But not all hospitals have ultrasound and not all anesthesiologists are skilled at performing ultrasound for spinal anesthesia, especially at the thoracic level.

Paresthesia can occur with any spinal procedure, but the greatest risk is when needle injection above the end of the spinal cord. Most paresthesia appears in spinal anesthesia in the lumbar region, namely 13.6%, but its clinical significance is not yet known.[8] This action has been proven safe in previous cases and even used for critical patient cases.[9]

TSA has been widely used for various procedures and is considered to have many advantages over general anesthesia and has been shown to be safe.[10] The combination of hyperbaric and isobaric can provide good onset of action, longer sensory duration and considered safe.[11] Hyperbaric will act predominantly on sensory block (posterior root) while isobaric (anterior root) will action to motor blockade dominantly.[12,13] The combination of these drugs will accelerate the onset of action and longer the duration of sensory blockade and also reduce the incidence of hypotension after spinal anesthesia.[14]

No dyspnea or low saturation and all the time oxygen saturation above 95%. This good condition perhaps can be explained because of using low degree of thoracic muscle blockade by of low dose hyperbaric bupivacaine and mixture with isobaric levobupivacaine. No shoulder pain was founded during laparoscope perhaps using adjuvant in intratracheal local anesthesia. Intrathecal was used fentanyl, ketamine and dexmedetomidine. Intrathecal adjuvant especially ketamine can improve quality of analgesia during laparoscope. Using of ketamine as adjuvant for intrathecal spinal anesthesia has been done and safe.[15]

CONCLUSION

This is only one single case report. TSA can be a better choice compare with general anesthesia. Stable hemodynamic during laparoscope and TSA can avoid systemic effect of general anesthesia like cognitive affect after general anesthesia, longer for recovery from anesthesia, nausea, vomiting, poor control pain and high cost.

DECLARATIONS

Ethics approval and consent to participate. Permission for this study was obtained from the Ethics Committee of Universitas Lampung.

CONSENT FOR PUBLICATION

The Authors agree to publication in Journal of Society Medicine.

FUNDING

This research has received no external funding.

AUTHORS’ CONTRIBUTIONS

MHRS collects the data and writes the initial manuscript. ERD provided contribution and revision regarding the data analysis and imaging aspect of the discussion. RH provided contribution and revision regarding the data analysis and clinical aspect of the discussion. All authors read and approved the final manuscript.

ACKNOWLEDGMENTS

Not applicable.

REFERENCE

  1. van Zundert AA, Stultiens G, Jakimowicz JJ, Peek D, van der Ham WG, Korsten HH, et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: A feasibility study. Br J Anaesth. 2007; 98:682–6.

  2. Takiguchi T, Yamaguchi S, Tezuka M, Kitajima T. Measurementof shift of the cauda equina in the subarachnoid space by changing position. Reg Anesth Pain Med. 2009; 34: 326-9

  3. Lee RA, Van Zundert AA, Breedveld P, Wondergem JH, Peek D, Wieringa PA. The anatomy of the thoracic spinal canal investigated with magnetic resonance imaging (MRI). Acta Anaesthesiol Belg. 2007; 58: 163-7

  4. Imbelloni LE, Quirici MB, Ferraz Filho JR, Cordeiro JA, Ganem EM. The anatomy of the thoracic spinal canal investigated with magnetic resonance imaging. Anesth Analg. 2010; 110: 1494-5

  5. Manion SC, Brennan TJ. Thoracic epidural analgesia and acute pain management. Anesthesiology. 2011; 115: 181-8

  6. Mahmoud AA, Hussein H, Kamal A, Nafady H, Girgis K. The novel use of spinal anesthesia at the mid-thoracic level: a feasibility study. Egypt J Cardiothorac Anesth. 2014;8: 21

  7. Eldeen HMS. Ultrasound guided pectoral nerve blockade versus thoracic spinal blockade for conservative breast surgery in cancer breast: a randomized controlled trial. Egypt J Anaesth. 2016; 32: 29-35

  8. Pong RP, Gmelch BS, Bernards CM. Does a paresthesia during spinal needle insertion indicate intrathecal needle placement?. Reg Anesth Pain Med. 2009; 34: 29-32

  9. van Zundert AA, Stultiens G, Jakimowicz JJ, van den Borne BE, van der Ham WG, Wildsmith JA. Segmental spinal anaesthesia for cholecystectomy in a patient with severe lung disease. Br J Anaesth. 2006; 96:464–6.

  10. Khan, Imran & Paliwal, Naresh & Ahmad, Shahbaz. (2022). Safety and Feasibility of Segmental Thoracic Spinal Anaesthesia (STSA): A Scoping Review. Scholars Journal of Applied Medical Sciences. 2022; 1718-1722.

  11. Eckert S, Standl T. Single-dose Spinalanästhesie mit einer Mischung aus Bupivacain 0.5% isobar und Mepivacain 4% hyperbar [Single-dose spinal anesthesia with a mixture of isobaric bupivacaine 0.5% and hyperbaric mepivacaine 4%]. Anaesthesist. 1997 Feb;46(2):121-5.

  12. Imbelloni L, Gouveia M, Ghorayeb N, Neto S. Spinal anesthesia: much more than single shot of hyperbaric bupivacaine. Int J Anaesth Anesthesiol. 2021; 8: 122

  13. Gouveia MA, Imbelloni LE. Understanding spinal anesthesia. Acta Anaesthesiol Scand. 2006; 50: 259-60

  14. Quan, Z., Tian, M., Chi, P., Li, X., He, H., & Luo, C. (2015). Combined Use of Hyperbaric and Hypobaric Ropivacaine Significantly Improves Hemodynamic Characteristics in Spinal Anesthesia for Caesarean Section: A Prospective, Double-Blind, Randomized, Controlled Study. PLOS ONE. 2015; 10(5), e0125014.

  15. Vincenzi P, Stronati M, Isidori P, Iuorio S, Gaudenzi D, Boccoli G, Starnari R. Opioid-Free Segmental Thoracic Spinal Anesthesia with Intrathecal Sedation for Breast and Axillary Surgery: Report of Four Cases. Local Reg Anesth. 2022; 15:23-29.