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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 362-370

Continuous spinal versus continuous thoracic epidural anesthesia for major abdominal surgery in patients with chronic obstructive pulmonary disease


Department of Anesthesia and Surgical Intensive Care, Zagazig University, Zagazig, Egypt

Date of Submission23-Sep-2018
Date of Acceptance18-Dec-2018
Date of Web Publication29-Aug-2019

Correspondence Address:
MD Farahat I Ahmed
41 Elssehabah Street, Hadayek Alkobbah, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_77_18

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  Abstract 

Background Most anesthetists preferred general anesthesia for major abdominal surgery which was not devoid of complications in cases with chronic obstructive pulmonary disease (COPD). Recently, the use of neuraxial anesthesia is supported to avoid or decrease these complications. This study aimed at the description, evaluation, and comparison between the use of continuous spinal anesthesia (CSA) and continuous thoracic epidural anesthesia (CTEA) as a sole anesthesia for major abdominal surgeries in cases with COPD.
Patients and methods Sixty patients of both sexes aged 40–75 years with American Society of Anesthesiologists physical status classes II and III complaining of COPD scheduled for various elective major abdominal operations were included. According to the neuraxial block type, the patients were randomly assigned into two equal groups with 30 patients in each. The first group (CSA group) received continuous lumbar spinal anesthesia and the second group (CTEA group) received continuous thoracic epidural anesthesia. The data recorded included patients’ demographic data, characteristics of the used neuraxial blockade, hemodynamic changes, changes in pulmonary functions, incidence of the various side effects, and postoperative pain severity.
Results The final statistical analysis included 55 patients where five patients were excluded from the study. Although there were no statistically significant differences between both groups regarding demographics, hemodynamics, changes in pulmonary functions, side effects, surgeon, and patients’ satisfactions, and postoperative visual analog scale. The CSA group has faster block onset with less local anesthetic dose compared with the CTEA group (P<0.001). Also, there were statistically significant decrease in peak expiratory flow rate, forced expiratory volume in 1 s, and forced expiratory volume in 1 s/forced vital capacity at 1, 2, and 6 h postoperatively compared with the preoperative baseline values in both groups (P<0.05). Hypotension was significantly more frequent in the CTEA group than in the CSA group (P=0.047).
Conclusion Although both CSA and CTEA can be used for anesthesia and for postoperative analgesia in major abdominal surgery in COPD patients, the CSA was easier, safer, had faster onset, gave more predictable block, with less hemodynamic instability, and less technical failure compared with CTEA. The preoperative optimization of the lung functions, intraoperative close observation, and postoperative neuraxial analgesia with chest physiotherapy improved the outcome.

Keywords: abdominal surgery, chronic obstructive pulmonary disease, continuous spinal anesthesia, thoracic epidural anesthesia


How to cite this article:
Ahmed FI. Continuous spinal versus continuous thoracic epidural anesthesia for major abdominal surgery in patients with chronic obstructive pulmonary disease. Res Opin Anesth Intensive Care 2019;6:362-70

How to cite this URL:
Ahmed FI. Continuous spinal versus continuous thoracic epidural anesthesia for major abdominal surgery in patients with chronic obstructive pulmonary disease. Res Opin Anesth Intensive Care [serial online] 2019 [cited 2019 Nov 21];6:362-70. Available from: http://www.roaic.eg.net/text.asp?2019/6/3/362/265730


  Introduction Top


Chronic obstructive pulmonary disease (COPD) is an inflammatory process that affects both central and peripheral tracheobronchial tree, pulmonary parenchyma, and pulmonary vasculature. This inflammatory process is a chronic and progressive and results in poorly reversible narrowing of the small airways, changes of airway smooth muscle, increase of the mucus-secreting glands and goblet cells, and pulmonary perivascular fibrosis leading to pulmonary hypertension with subsequent increased right ventricular afterload. Finally, this disease process is characterized by airflow limitation during expiration caused by both inflammation of the small airways ‘obstructive bronchiolitis’ and destruction of the lung parenchyma ‘emphysema.’ The small airway obstruction produces air trapping and dynamic hyperinflation, which results in both ventilation/perfusion (V/Q) mismatching and impaired lung mechanics [1].

The inflammatory pathogenesis in COPD not only affects the lung but also has extrapulmonary manifestations that may be presented by weight loss, skeletal muscle dysfunction (with more adverse effects on respiratory muscle function), cardiovascular disease, depression, and osteoporosis [2].

The Global Initiative of Chronic Obstructive Lung Disease (GOLD) guidelines [3] defines COPD as follows: COPD is a preventable and curable disease associated with significant extrapulmonary manifestations which may contribute to the severity in individual patients. GOLD estimates expect that COPD will increase from the sixth to third common cause of mortality all over the world by 2020 [4].

The choice of anesthesia in COPD patients depends on the severity of the disease process, the surgical procedure, and duration of surgical procedure. It was known that the use of general anesthesia (GA), especially if combined with endotracheal tube insertion and mechanical ventilation, may lead to multiple adverse effects in patients with COPD. These complications include laryngeal spasm, bronchospasm, barotraumas of the lung, hemodynamic instability, hypercarbia, need for postoperative mechanical ventilation with failure of weaning, and hypoxemia with increased incidence of intra- and postoperative pulmonary complications. For these problems, there was increased trend for the use of variable types of regional anesthetic techniques for different types of surgical procedures whatever possible, including central neuraxial block. A previous retrospective [5] and prospective [6],[7] observational studies observed that the use of neuraxial blockade for nonthoracic surgeries had better pulmonary outcome in cases with severe COPD [5] or in cases with normal pulmonary functions [6],[7] compared with the use of GA.

Aim of the study

The current study aimed at the description, evaluation of the patient’s outcome, and comparison between the use of either continuous spinal anesthesia (CSA) and continuous thoracic epidural anesthesia (CTEA) as a sole anesthesia for major abdominal surgeries in patients with COPD.


  Patients and methods Top


This randomized, double-blinded, prospective study was conducted at Zagazig University Hospital over 12 months after approval from the Institutional Review Board (IRB) and written informed consent form all patients had been taken. The study included 60 patients of both sexes aged 40–75 years with the American Society of Anesthesiologists (ASA) physical status classes II and III, who had COPD and were scheduled for various elective major abdominal operations that were expected to last for more than 2 h as intra-abdominal malignancy, liver resection, or gastrointestinal surgical procedures.

All the selected patients were known that they had COPD with stages I–III (mild to severe airflow limitation) with forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) less than 70% of the normal value as per GOLD ([Table 1]) [3]. According to the neuraxial block type, the selected patients were randomly assigned into two equal groups, 30 patients in each. The first group (CSA group) received continuous lumbar spinal anesthesia and the second group (CTEA group) received continuous thoracic epidural anesthesia.
Table 1 Global Initiative of Chronic Obstructive Lung Disease classification of airflow limitation severity in chronic obstructive pulmonary disease (based on postbronchodilator forced expiratory volume in 1 s) in patients with forced expiratory volume in 1 s/forced vital capacity less than 0.7

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Exclusion criteria

  1. Patients’ refusal of neuraxial anesthesia and prefer GA.
  2. Patients with local back infection.
  3. Patients with lumbar or thoracic spine deformity.
  4. Coagulopathy or platelet dysfunction.
  5. Peripheral or central neurological dysfunctions.
  6. Diabetic patients.
  7. Organ failure.
  8. Failed neuraxial block.
  9. Systolic pulmonary artery pressure of more than 50 mmHg.
  10. Obese (BMI >30).
  11. Ejection fraction of less than 50%.
  12. Emergency surgery.
  13. Uncontrolled hypertension.
  14. Serum albumin of less than 3.5 g/dl.
  15. ASA physical status class of less than III.
  16. PaCO2 of more than 45 mmHg and PaO2 of less than 60 mmHg on room air.
  17. Patients with allergy to local anesthetic (LA) drugs.


Preoperative management

Patients were visited preoperatively for the assessment of the patient’s medical condition (via history taking, through clinical examination, and review investigations), giving instructions to make the patient familiar with the visual analog scale (VAS) for pain severity assessment, and optimization of pulmonary functions by stopping of smoking for at least 8 weeks, chest physiotherapy, bronchodilators, steroids, and antibiotics for treatment of chest infection.
  1. Preoperative investigations included complete blood count, coagulation profile, liver function tests, renal function tests, chest radiography, ECG, echocardiography, arterial blood gas analysis, serum electrolytes, and pulmonary functions.
  2. ICU bed was reserved for each patient in the ICU before surgery.


In the operating room

  1. Before regional block, a wide-bore peripheral intravenous line and central line insertion and base level central venous pressure were recorded and then 500 ml lactated Ringer’s solution was given.
  2. After making sure positive Allen test, an arterial line insertion in the radial artery of the nondependent arm for ABG sampling and invasive blood pressure monitoring.
  3. Monitoring included ECG, oximetry, noninvasive blood pressure, respiratory rate (RR), skin temperature, invasive blood pressure, central venous pressure, and urine flow rate.


Regional block

The epidural kit (Perifix; B. Braun Melsungen AG, Melsungen, Germany) which is designed for epidural placement was used in both techniques with an 18 G Tuohy needle and 20 G epidural catheter. The block was done in the sitting position or lateral if the sitting was difficult. Under complete sterile precautions, LA infiltration was done using 3–5 ml 2% lidocaine of the predetermined interspinous space.
  1. CSA group:
    • At L2–3 or L3–4 space: Once the epidural space was confirmed by loss of resistance technique, the epidural catheter was inserted into the needle but not behind its tip. The epidural needle was advanced gently through the dura into the subarachnoid space. After verification of free cerebrospinal fluid (CSF) flow, the catheter was threaded into the subarachnoid space and advanced 3 cm in the cephalad direction and then Tuohy needle was removed. Both adapter and bacterial filter were connected to the catheter which was fixed and covered well to the patient back and then the patient was turned to supine position. After CSF aspiration, 25 μg fentanyl (Fentanyl Hameln 0.1 mg/2 ml manufactured by Sunny Pharmaceutical under license of Hameln Pharmaceutical, 100 Acre Industrial Zone, Badr City, Egypt) in 1 ml normal saline was injected followed by an initial dose of 2.3 ml 0.5% heavy bupivacaine (Marcaine spinal heavy 0.5% by Astra Zeneca, Buyukdere Cad. YapiKredi Plaza B Blok Kat: 3-4 Levent, Istanbul, Turkey). Dead space in the adaptor, bacterial filter, and the catheter was 0.8 ml. Bilateral sensory block was assessed by loss of pinprick sensation in both midclavicular lines every 2 min. If the sensory block level was still below T5 after 10 min, additional doses of 0.5 ml 0.5% bupivacaine were injected at 5 min intervals until a T5 sensory block level was achieved. During surgery, 0.5–1 ml of 0.5% bupivacaine was given. Top-up doses were given if there were two segments sensory regression or patient feeling of pain. Postoperative analgesia was maintained with intrathecal administration of 1 ml of 0.5% bupivacaine plus 15 μg fentanyl in 2 ml normal saline through the catheter every two hours. If the VAS is more than or equal to 3, a rescue analgesic dose of 1 ml of 0.25% bupivacaine every 15 min, with a maximum of three boluses per hour was given.
  2. CTEA group
    • At T6–8 space, the epidural needle was inserted. After verification of the epidural space by resistance loss technique, a test dose of 2 ml of 0.5% bupivacaine–adrenaline (1/200 000) was injected. The epidural catheter was threaded into the epidural space 3 cm in the cephalad direction. After confirmation of the catheter position, a total dose of 8–12 ml 0.5% plain bupivacaine plus 100 μg fentanyl was administered in the epidural catheter in 4 ml divided aliquots at 5 min intervals. Bilateral sensory block was assessed by loss of pinprick sensation in both midclavicular lines every 2 min. After 15 min, if the sensory block level was still below T5, an additional 3–5 ml bupivacaine was given. Epidural anesthesia was maintained by injecting one-fourth to one-third of the initial LA dose when there is two segment sensory regression. Postoperative analgesia was maintained by epidural infusion of a mixture of 0.125% bupivacaine plus fentanyl 2 ug/ml at a rate of 6–10 ml/h with infusion rate adjustment according to VAS and side effects. Rescue analgesic dose of 5 ml 0.125% bupivacaine was given when the VAS was more than or equal to 3 every 15 min with a maximum three boluses per hour.


In both groups, motor blockade was evaluated by the modified Bromage scale [8] (0 the patient can flex the extended leg at the hip, 1 can flex the knee but cannot flex the extended leg, 2 can move foot only, 3 cannot move foot). Oxygen was given to all patients by a nasal catheter at a rate of 2 l/min. Bradycardia [heart rate (HR)<55 beat/min] was treated with 0.5–2 mg intravenous atropine and the hypotension [mean arterial pressure (MAP) <20% of preoperative value] was treated with intravenous 5 mg ephedrine in increments. Vomiting was treated by intravenous 10 mg metoclopramide.

After surgery, all patients were transferred into the surgical ICU for monitoring, clinical evaluation, and management of any problem. The intrathecal or the thoracic epidural catheter was used for postoperative analgesia and removed in both groups at ICU discharge or before if associated with complications or migrated outside the space. The postoperative analgesia was assessed by the VAS every 2 h in addition to observation for its undesirable side effects such as respiratory depression, vomiting, pruritus, motor block, and hemodynamic instability.

Data recorded

  1. Patient’s demographic data (age, body weight, sex ratio, ASA PS classes, and GOLD staging) and duration of surgery.
  2. Characters of each neuraxial block:
    1. Technical ease of the needle insertion and catheter threading through it. The degree of ease is classified as very easy, easy, difficult, and very difficult.
    2. Initial total dose of LA that was needed to obtain T5 sensory block level.
    3. Time to T5 sensory block level.
    4. Total LA dose that was required until end of surgery.
  3. Hemodynamic changes: HR and MAP, preoperatively (baseline values), intraoperatively at 30 min, 1 h, at end of surgery, and postoperatively at 1 h after surgery.
  4. Respiratory changes: RR (min), PaCO2 (mmHg), and PaO2 (mmHg) preoperatively (baseline values), intraoperatively at 30 min, 1 h, at end of surgery, and postoperatively at 1 h after surgery. Pulmonary mechanics including peak expiratory flow rate (PEFR), FEV1, and FEV1/FVC preoperatively (baseline values) and postoperatively at 1, 2, and 6 h.
  5. The rate of intraoperative requirement for noninvasive ventilation and sedation.
  6. The incidence of various side effects such as hypotension (MAP<20% of baseline value), bradycardia (HR<55 b/m), vomiting, pruritus, respiratory depression (RR<8 breath/min), and post dural puncture headache (PDPH).
  7. Patient’s and surgeon satisfaction that were evaluated by using a four-point scale (4 is excellent, 3 is good, 2 is satisfactory, and 1 is poor), and the length of ICU stay.
  8. Pain severity was evaluated via VAS postoperatively at 2, 6, 12, and 24 h postoperatively.


The data were recorded by an investigator who was blinded about the type of block.

Statistical analysis

Data were checked, entered, and analyzed by using IBM SPSS, version 20 (SPSS Inc., Chicago, Illinois, USA). Data were represented as mean±SD for continuous variables, numbers, and percentage for categorical variables. χ2 or Fisher’s exact results and test were used when appropriate. P value less than 0.05 was considered statistically significant and P value less than 0.001 was highly significant.

Sample size

Sample size was calculated as minimum, 37 patients, based on the FEV1 as a primary outcome, to provide 90% power and α=0.05. We decided to study 60 patients to account for possible dropouts.


  Results Top


Sixty patients were enrolled in the study but 55 cases were included in the final analysis. A total of five patients were excluded where one patient in the CSA group and two patients in the CTEA group needed GA during surgery. Also, two patients in the CTEA group had failed block technique. There were no significant differences between both groups regarding the demographic variables, GOLD staging, and duration of surgery ([Table 2]).
Table 2 Patient’s demographic data, Global Initiative of Chronic Obstructive Lung Disease staging for chronic obstructive pulmonary disease, and duration of surgery

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There was no statistically significant difference between both groups regarding the ease of the technique including needle insertion and catheter threading through the Tuohy needle. However, practically the lumbar IT needle insertion and catheter threading was easier in the CSA group than the thoracic epidural approach technique in the CTEA group. On the other side, the total dose of bupivacaine to obtain T5 sensory block level and the total dose of injected LA till the end of surgery in the CSA group were highly significantly less than that used in the CTEA group. Also, the time to T5 block level was highly significantly shorter in the CSA group than in the CTEA group ([Table 3]).
Table 3 Technical ease, dose of bupivacaine, and the time to T5 sensory block level

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The corresponding HR and MAP values preoperatively (baseline values), at various times of intraoperative measurements, and at 1 h postoperatively in both groups were statistically comparable. However, statistically, the MAP values at various times of intraoperative measurements in both groups were highly significantly lower than the corresponding baseline values (P<0.01). Statistically, the HR measurements values at various times of intraoperative measurements in both groups were comparable with the corresponding baseline value ([Table 4]).
Table 4 Preoperative, intraoperative, and 1 h postoperative heart rates and mean arterial pressure

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For the arterial blood gas analysis, the corresponding PaCO2 and PaO2 values preoperatively (baseline values), at various times of intraoperative measurements and at 1 h postoperatively in both groups were statistically comparable. However, statistically, the PaO2 values at various times of intraoperative measurements and at 1 h postoperatively in both groups were significantly higher than the corresponding baseline values in both groups ([Table 5]).
Table 5 Preoperative, intraoperative, and 1 h postoperative arterial PaCO2 and PaO2 tension in both groups

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The corresponding RR values preoperatively (baseline values), at various times of intraoperative measurements and at 1 h postoperatively of both groups were statistically comparable. Also statistically, RR values at various times of intraoperative measurements and at 1 h postoperatively in both groups were comparable with the corresponding baseline values. The corresponding PEFR, FEV1, and FEV1/FVC values preoperatively (baseline values), and at 1, 2, and 6 h postoperatively in both groups were statistically comparable. However, statistically, the PEFR, FEV1, and FEV1/FVC values at 1, 2, and 6 h postoperatively in both groups were significantly lower than the corresponding preoperative baseline values (P<0.05) ([Table 6]).
Table 6 Perioperative respiratory rate, peak expiratory flow rate, forced expiratory volume in 1 s, and FEV1/forced vital capacity

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There were no significant differences between both groups regarding the patients who required intraoperative noninvasive ventilatory support and sedation. Although the incidence of side effects was comparable in both groups, the incidence of hypotension was significantly higher in the CTEA group than in the CSA group (Р=0.047). Moreover, the PDPH occurred in three patients in the CSA group but did not occur in the CTEA group ([Table 7]).
Table 7 Requirement for noninvasive ventilation and sedation and the incidence of various side effects in both groups

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Statistically, the corresponding degrees of patient and surgeon satisfaction besides the length of ICU stay, and VAS values at various times of measurements postoperatively within the first 24 h in both groups were comparable ([Table 8] and [Table 9]).
Table 8 Patients and surgeon satisfaction, duration of ICU stay

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Table 9 Postoperative visual analog scale in the first 24 h

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  Discussion Top


Most anesthetists preferred GA over neuraxial blockade in major abdominal operations because of multiple reasons including prolonged duration of surgery, hemodynamic instability due to the high level of block, incomplete muscle relaxation, vomiting, and visceral pain. However, the use of GA with endotracheal intubation in patients with COPD was associated with increased intraoperative and postoperative complications. These complications included pneumonia, unplanned postoperative intubation, and prolonged ventilator dependence, pneumothorax, and prolonged ICU stay with increased rate of mortality [5],[9],[10]. Recently, neuraxial anesthesia was supported in patients at risk of GA. Moreover, it has multiple advantages including induced vasodilation with decrease of both preload and afterload so that the patients with Cor Pulmonale will benefit from this effect, disrupts surgery-induced reflex inhibition of the phrenic nerve, improves chest wall compliance by decreasing chest wall muscle tone [11], and can be used for postoperative analgesia in patients with COPD.

The current study described, evaluated, and compared between both CSA and CTEA in major abdominal surgeries in patients with GOLD classes I–III of COPD. There were three (10%) cases with technical failure in the CTEA group but no block failure was encountered in the CSA group. This may be explained by the fact that in CSA, the epidural catheter was threaded through Tuohy needle into the subarachnoid space after verification of the CSF flow but in CTEA, the possibility of epidural catheter migration outside the epidural space increases the failure rate. Our results are similar to a previous retrospective study which reported 9% rate of block failure in CEA compared with 1.7% failure rate in CSA [12].

In the present study, the perioperative hemodynamic variables were comparable in both groups. There was significant decrease in the intraoperative MAP compared with the preoperative baseline values due to the high level of block in both groups. This decrease in MAP was noticed late in CSA but it was early in CTEA and the incidence of hypotension was higher in the CTEA group than in the CSA (50 vs. 24%), respectively. This may be explained by the use of very small titrated doses of LA in CSA compared with larger doses of LA in CTEA that were used to obtain the desired block level. Hypotension was easily treated in both groups with intravenous fluids and increments of intravenous ephedrine. These results were similar to multiple previous studies where different types of surgeries were carried out under neuraxial anesthesia [13],[14],[15],[16],[17].

In noncooperative patients, if the patient reassurance was ineffective, small titrated doses of sedatives were used cautiously. Sedation was carried out by using intravenous injection of 0.5–2 mg midazolam or intravenous infusion of propofol at a rate of 0.1 mg/kg/min for 3–5 min and then adjusting the infusion rate to obtain levels II–III of Ramsay sedation scale [18] to avoid the possibility of respiratory depression and or airway obstruction.

In the current study, from a practical point of view, it was not applicable to measure the respiratory mechanics intraoperatively because the ability of the patients to create a positive intra-abdominal pressure by abdominal muscle contraction was lost by abdominal muscle blockade and laparotomy. Postoperatively, within the first 6 h there was a decrease in PEFR, FEV1, and FEV1/FVC by about 7–15% from the preoperative basal corresponding values. However, there were no changes in the intraoperative and postoperative oxygenation and CO2 elimination. The PaO2 increased intraoperatively and postoperatively more than the preoperative baseline values due to the use of oxygen by a nasal cannula.

There are very little published studies that evaluated the effect of neuraxial anesthesia for major abdominal surgery on the pulmonary functions tests (PFTs) in COPD patients. The effect on the PFTs depends on the level and intensity of block, the type of surgery, and severity of COPD [19]. The results of PFTs in the present study are similar to that noticed in a previous study, where there was reduced inspiratory capacity and expiratory reserve volume from 20–0% after T5 level neuraxial anesthesia [20]. The diaphragmatic function, however, is usually preserved, even in patients of inadvertent extension of neuraxial block to cervical levels [21].

On the other side, previous studies had reported no changes in PFTs after neuraxial anesthesia at the lumbar level for lower abdominal and lower limb surgeries either in patients with COPD [22] or those with normal pulmonary functions but in morbidly obese patients there was a 20–25% fall in expiratory functional volumes (FEV1 and FVC) [23]. Savas et al. [11], had reported eight patients with severe pulmonary disease who were successfully operated upon for abdominal surgery under epidural anesthesia alone with T4–6 block level. Also, combined lumbar spinal and thoracic epidural anesthesia had been successfully used as a sole anesthetic technique for nephrectomy in patients with COPD with recurrent episodes of tension pneumothorax [10].

In both blocks, the high block level limited the expiratory force in some patients especially those with GOLD 2 and 3 classification of COPD due to blockade of the abdominal and intercostal muscles. In the present study, from the total enrolled 60 patients, seven patients required intraoperative noninvasive ventilation support, with two patients in the CSA group and five in the CTEA group having an 11.7% total incidence of intraoperative noninvasive ventilation. The noninvasive ventilation failed to support ventilation in three patients where GA was carried out. The three patients who were converted to GA were excluded from the study. These results are not in agreement with the study by Savas et al. [11] where no patient in their study needed noninvasive ventilation nor converted to GA. Their study was conducted on eight patients only who had surgical and pulmonary criteria different from the present study.

The higher incidence for the need of noninvasive ventilation support in the CTEA group compared with the CSA group may be explained by the use of larger LA doses in the CTEA that was injected at the thoracic level, which may induce more intense motor blockade of the abdominal and intercostal muscles. For early detection of ventilatory failure, intraoperative monitoring by close observation of the pattern of breathing, oximetry, serial arterial blood gases analysis, frequent chest auscultation, and bronchodilator therapy if required in patients with bronchospasm are mandatory.

The postoperative pain and the decrease of FEV1 will decrease the clearance of bronchial secretion with subsequent bronchial obstruction, atelectasis, and hypoxemia due to V/Q mismatch. To avoid or decrease this problem, postoperative analgesia and aggressive chest physiotherapy were done by chest percussion, deep breathing, and encouraging the patients to cough and expectorate. The postoperative VAS values were comparable in both groups. This finding was supported by previous studies that used thoracic neuraxial anesthesia and analgesia in patients with COPD with decreased postoperative pulmonary complications [24],[25].

In this study, there were few cases with mild undesirable side effects such as bradycardia, vomiting, pruritus, and respiratory depression in both groups. The hypotension was more evident in CTEA than in CSA. But, the PDPH occurred in three patients after CSA with 10% incidence but no cases were noticed in CTEA. In addition, the degree of satisfaction for patients and surgeons was excellent and good in most cases in both groups. The length of postoperative ICU stay was short with improved patients’ outcome.


  Conclusion Top


Both CSA and CTEA can be used safely as a sole neuraxial anesthesia and for postoperative analgesia in major abdominal surgery in COPD patients with minimal side effects. The present study recommended the use of CSA as it was easier, safer, had faster onset, gave more predictable block, less hemodynamic instability, and less technical failure compared with CTEA. Good preoperative optimization of the lung functions, intraoperative close observation, the use of postoperative neuraxial analgesia, and chest physiotherapy are mandatory to improve the outcome.

Limitations of the study

The sample size was small. The respiratory affection due to high level of neuraxial blockade was noticed more in patients with GOLD 3 class of COPD and the possibility for noninvasive ventilatory support.

Acknowledgements

The author acknowledge Dr Mohamed Saad, Lecturer of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, for his help in data collection and in conducting the double-blinded study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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