Lumbar epidural anesthesia in a high-risk patient with advanced lung cancer, multi-organ metastasis and hydropneumothorax: A case report

Ahmed Uslu; Nedim Çekmen

doi:10.4103/bjoa.bjoa_248_22

CASE REPORT

Year : 2023 | Volume : 7 | Issue : 1 | Page : 47-50

Lumbar epidural anesthesia in a high-risk patient with advanced lung cancer, multi-organ metastasis and hydropneumothorax: A case report

Ahmed Uslu, Nedim Çekmen
Department of Anesthesiology, Başkent University, Ankara, Turkey

Date of Submission	06-Nov-2022
Date of Decision	08-Dec-2022
Date of Acceptance	29-Dec-2022
Date of Web Publication	6-Mar-2023

Correspondence Address:
Ahmed Uslu
Department of Anesthesiology, Başkent University, Yukari Bahçelievler Mareşal Fevzi Cakmak St. No: 45, Çankaya, Ankara 06490
Turkey

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjoa.bjoa_248_22

Abstract

Epidural anesthesia (EA) can be applied in the perioperative period (PP) in addition to general anesthesia (GA) or as a stand-alone anesthesia technique. EA provides better hemodynamic stability in high-risk patients, reduced neurohormonal surgical stress response, and preserved airway reflexes with spontaneous breathing. In addition, EA prevents pulmonary dysfunction through decreasing multifactorial mediators, improves pulmonary functions by reducing the decrease in functional residual capacity, and protects spontaneous respiratory and airway reflexes. Herein, we wanted to emphasize the importance of the perioperative approach, the choice of anesthesia technique, and the effects of this choice on the postoperative period in a high-risk patient with incidental stage four lung adenocarcinoma, right parietal brain, lumbar vertebral, liver, and adrenal metastasis, as well as hydropneumothorax. With a successful epidural catheterization and anesthesia, the patient was follow-up without any problems. As in our patient, we should adopt a multimodal approach in the perioperative period, perform a detailed examination before the operation, and evaluate all risks and benefits comparatively when choosing the most appropriate anesthesia technique. Thus, it should be kept in mind that the chosen technique will significantly affect perioperative complications, morbidity and mortality, drug use, length of hospital stay, and cost.

Keywords: Advanced lung cancer, epidural anesthesia, high-risk patient, hydropneumothorax, multiple metastases

How to cite this article:
Uslu A, Çekmen N. Lumbar epidural anesthesia in a high-risk patient with advanced lung cancer, multi-organ metastasis and hydropneumothorax: A case report. Bali J Anaesthesiol 2023;7:47-50

How to cite this URL:
Uslu A, Çekmen N. Lumbar epidural anesthesia in a high-risk patient with advanced lung cancer, multi-organ metastasis and hydropneumothorax: A case report. Bali J Anaesthesiol [serial online] 2023 [cited 2023 Mar 21];7:47-50. Available from: https://www.bjoaonline.com/text.asp?2023/7/1/47/371179

Introduction

Epidural anesthesia (EA) is used in addition to general anesthesia (GA) in the perioperative period (PP) or as a stand-alone method. It is known that EA provides better hemodynamics and stability in high-risk conditions such as congestive heart failure and pulmonary hypertension, thus preventing the effects of intubation and mechanical ventilation on pulmonary circulation in awake patients.^[1],[2] It is known that EA reduces the neurohormonal response due to surgical stress, and as a result, it prevents pulmonary dysfunction through multifactorial mediators whose release is reduced.^[3] It improves pulmonary functions by reducing the decrease in functional residual capacity and protects spontaneous respiration and airway reflexes. Maintaining chest wall compliance and diaphragm contractility preserves vital capacity.^[1] EA provides adequate postoperative analgesia and reduces postoperative nausea and vomiting.^[4] It also reduces the length of stay, postoperative morbidity, and mortality rate in high-risk patients.^[5],[6]

Herein, we present the preferred anesthesia method and perioperative management in a patient who was admitted to the hospital with a femoral neck fracture, was diagnosed with incidental stage 4 lung cancer during the preoperative evaluation and had metastases in the brain, liver, adrenal gland, and lumbar vertebrae, and hydropneumothorax was detected. Ethics committee approval and the patient’s relatives written and informed consent for the publication of this case report were obtained.

Case Report

A 77-year-old male patient was admitted to our hospital with a left femoral neck fracture, and the orthopedics made a left partial hip replacement decision. In the preoperative evaluation, the patient stated that he had no comorbidities and did not smoke. However, physical examination revealed that he had hemoptysis and lung sounds decreased significantly on the left side on lung auscultation. Chest X-ray showed a near-total collapse in the left lung and a prominent hydropneumothorax in the upper zone [Figure 1]. In thoracoabdominal computed tomography taken for further diagnosis, a mass compatible with stage 4 lung carcinoma surrounding the left main branch of the pulmonary artery in the left upper lobe of the left lung, hydropneumothorax on the left, bilateral multiple satellite nodules, metastases in the liver and adrenal glands, and multiple lymph nodes in many foci were detected [[Figure 2]a and b]. Lumbar vertebral magnetic resonance imaging (MRI) revealed metastases in the L5 vertebral body, the right half of the sacrum, and the right iliac bone [[Figure 3]a]. On the brain MRI, there was metastasis at the level of the precentral gyrus in the left frontal region [[Figure 3]b]. On echocardiography, he had moderate pulmonary hypertension due to left pulmonary artery involvement, and systolic pulmonary artery pressure was 55 mmHg. The patient was determined as an American Society of Anesthesiology class 4. The risk of prolonged mechanical ventilation and length of stay after GA was high. Moreover, the patient refused the peripheral block techniques due to personal and psychological reasons. Thus, EA was preferred. The existing risks and EA method were explained to the patient, whose preoperative preparations were completed.

Figure 1: Chest X-ray showed a near-total collapse in the left lung and a prominent hydropneumothorax in the upper zone

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Figure 2: Thoracoabdominal computed tomography, a mass compatible with stage 4 lung carcinoma (a) surrounding the left main branch of the pulmonary artery in the left upper lobe of the left lung (a) and hydropneumothorax on the left (a and b)

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Figure 3: Lumbar MRI revealed metastases in the L5 vertebral body, the right half of the sacrum, and the right iliac bone (a). In the brain MRI, there was metastasis at the level of the precentral gyrus in the left frontal region (b)

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The patient was taken to the operating room on the day of surgery, and standard monitoring (electrocardiography, noninvasive blood pressure, heart rate, and pulse oximetry) was performed. Fluid therapy was started with the intravenous (IV) catheter. Vital signs were stable. Due to metastasis in the L5 lumbar vertebra, it was decided to insert an epidural catheter from a higher level, L1/L2 interspinous area. The patient was placed in the left lateral position. Under the conditions of asepsis and antisepsis, prilocaine 2% 2.5 mL was administered subcutaneously to the patient for local anesthesia. Then, the epidural space (ES) was entered using the hanging drop technique with an 18G epidural needle. It was 5 cm from the skin to the ES. The catheter was placed 5 cm into the ES. Adrenaline was administered with 1 mL 1:100,000 for the test dose and decided that the catheter was in the ES. Bupivacaine 0.5% 15 mL was given as a slow bolus over 5 min. After waiting for 10 min in the lateral position, the patient was placed supine, sensory control was performed with cold and pinprick tests, and decided that the block was at the L2-L3 level. Respiration was supported with nasal O₂ 3 L/min. For sedation, IV dexmedetomidine 1 μg/kg bolus was administered to the patient in 10 min, and an infusion of 0.7 μg/kg/h was started. Invasive arterial monitoring was performed on the sedated patient. The operation started 20 min after the epidural bolus dose. The pain level of the patient, who was hemodynamically stable in the PP, was evaluated as zero according to the visual pain scale throughout the operation. The degree of motor block was evaluated according to the Bromage scale. Two segment regression times were followed for the need for an additional epidural bolus. Arterial blood gas (ABG) was normal [Table 1]. The estimated blood loss was 100 mL, and 1000 mL of crystalloid fluid was given to the patient. The process took 1 h and 35 min. There were no complications in the PP. Epidural bupivacaine 0.5% 4 mL/h infusion was started for postoperative analgesia. The patient was followed up in the intensive care unit (ICU) for one night due to his current comorbidities and close follow-up. At admission to ICU, the Apache II score was 12, and the estimated postoperative mortality was only 7%. His vital signs were stable, and ABG parameters and laboratory results were within the normal range in the ICU [Table 1]. The epidural catheter was removed on the second postoperative day. The patient was transferred to the ward on the first postoperative day and discharged on the fourth day without complications.

Table 1: Intraoperative and postoperative arterial blood gas parameters

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Discussion

EA stands out when compared to GA in many aspects, such as hemodynamic stability, pulmonary circulatory and physiological stability, decreased neurohormonal stress response, early mobilization, and decreased hospital stay in high-risk patients.^[1],[2],[3] Also, prolonged mechanical ventilation, increased morbidity, and mortality are noteworthy in high-risk patients receiving GA.^[5],[6]

When we reviewed the literature, we could find very few studies in which perioperative management was performed with EA alone in a high-risk patient.

Kolker et al. ^[5] in their study with 81 patients, compared EA and GA in high-risk patients and reported that postoperative pulmonary complications and hospital stays were fewer in the EA group. In our case, no pulmonary complications or respiratory problems were detected from the postoperative period to discharge, and our patient was followed up in the ICU for one night and was discharged on the fourth postoperative day.

Koltun et al. ^[6] applied EA to 15 high-risk patients and GA to 17 low-risk patients among 32 patients who were scheduled for colectomy. When these two groups were compared, they stated that postoperative intestinal motility was better and the amount of bleeding and hospitalization time was less in high-risk patients who underwent EA. In our case, the bleeding was only 100 mL, the hospital stay was short, and there was no postoperative motility delay.

In a case report presented by Srivastava et al.^[7] thoracic EA was preferred for a high-risk patient who was planned for radical mastectomy, and they stated that airway safety was better. Polat et al.^[8] preferred thoracic EA for the high-risk patient who was planned for total gastrectomy and stated that morbidity and mortality were less in these patients. In our case, the airway and respiration were stable in the PP. At admission to the ICU, the Apache II score was 12, and the estimated postoperative mortality was only 7%.

As in our case, we should adopt a multimodal approach in the PP to a high-risk patient due to comorbidities, perform a detailed examination before the operation, follow closely by choosing the most appropriate anesthesia technique, and comparatively consider all risks and benefits when choosing the technique to be applied to the patient.

Conclusion

Herein, we wanted to emphasize the importance of the perioperative approach, the choice of anesthesia technique, and the effects of this choice on the postoperative period in a high-risk patient. Because it should be kept in mind that the choice of anesthesia technique will significantly affect perioperative complications, morbidity and mortality, drug use, length of hospital stay, and cost in such patients.

Author’s Contribution

AU: designed and performed the interventional therapy. NC: drafted and critically reviewed the article and provided constructive suggestions. All authors read and approved the final article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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