LOW DOSE COMBINED SPINAL EPIDURAL FOR GENITAL PROLAPSE OPERATION ON ELDERLY PATIENTS

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LOW DOSE COMBINED SPINAL EPIDURAL FOR GENITAL
PROLAPSE OPERATION ON ELDERLY PATIENTS

• Le Minh Tam, MD
• and his collaborators

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BACKGROUND (1)

• Before, uterine prolapsed operation were
  performed for the patients under 60 years old, at
  Hung Vuong Hospital.
• Today, life expectancy is longer. So, the needs
  to operate on these patients increase, especially
  at age of group 60 80.

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BACKGROUND(2)

• An anesthesia method of choice for these patients
  concern little effects on hemodynamic status, or
  metabolism and or respiration.
• Combined Spinal Epidural Anesthesia can
  decrease greatly the anesthetic dose. So, it can
  also decrease side effects of each method but
  still has good results.

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OBJECTIVES

• 1.General objectives
• Assess frequent complications due to CSE and the
  management.
• Determine the suitable dose for these operations
• Evaluate properly postoperative analgesia dose
  and postoperative analgesia effects.

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OBJECTIVES

• 2. Special objectives
• Evaluate frequent complications due to CSE with
  low dose for these operations on the elderly
• Perform postoperative analgesia at ICU in first
  24 hours
• Extend indications of operation on high risk
  patients

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LITERARTURE REVIEW

• Anesthesia for the elderly
• Changes of the anatomy, physiology, psychology
  and pharmacodynamy with latent diseases are
  clearly inconveniences and dangers for anesthesia
  and operation

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METABOLISM

• Decrease activities of metabolic enzymes
• Diminish detoxication functions of the liver and
  endothelial reticular system
• Alter excretion function (kidney, gallbladder)
• ? over dose easily leading to toxic reaction and
  prolonged actions

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CARDIOVASCULAR SYSTEM

• Older patients over 60 years old must be
  considered as coronary insufficiency with latent
  anoxia. Hypoxia, instable blood pressure and
  sudden tachycardia must be avoid during the
  anesthesia.

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RESPIRATORY SYSTEM

• Limited thorax distention reduced lung compliance
  
• Reduced lung diffusion, PaO2 affinity of CO2 and
  O2
• Emphysema, asthma, lung fibrosis and
  bronchodilatation commonly with the elderly.
• Multiple small atelectasis, pulmonary congestion,
  bronchal mucus plugs and infection contribute to
  increase right ventricular work
• To reduce these complications for the elderly,
  regional anesthesia may be the first choice.

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ANESTHESIA AND OPERATION RISKS OF THE ELDERLY
PATIENTS

• Over 70 years old, risks increase 4 times for
  schedule surgery and 8 times in case of
  emergency. Otherwise, decision for surgery
  depends on the concurrent diseases, patient
  conditions, surgeon experiences and anesthetists
• Mortality rate increase with age
• Over 60 3 times
• Over 70 4,5 times
• Over 80 5,3 times

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METHODS OF ANESTHESIA

• Regional analgesia includes
• Spinal anesthesia
• Epidural anesthesia
• Combined Spinal and Epidural anesthesia (CSE)

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SPINAL ANESTHESIA

• Advantages
• Rapid onset (1-2 minutes)
• Intense block (good muscle relaxation)
• Disadvantages
• Hypotension effects altering the hemodynamic
  status, uncontrolable motor block, the likely
  affecting the respiration
• Difficult technique in case of vertebral
  deformity of the older people.
• Urinary retention is common

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EPIDURAL ANESTHESIA

• Advantages
• Lesser hypotension
• Lesser effects on the hemodynamic status.
• Disadvantages
• Slow onset 15 20 minutes
• Aministration of large dose of anesthetics likely
  leading to toxic effects, mostly with large dose
  of Marcain 0,5
• Asymmetrical block

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CSE

• Advantages
• Rapid onset
• Lesser effects on hemodynamics and respiration,
  better muscle relaxation than those of epidural
  anesthesia
• Duration may be prolonged
• Complete the inoppriate effects of Spinal
  anesthesia
• Postoperative analgesia available

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CSE

• Disadvantages
• Need experience of the anesthetist
• Determine testing dose difficultly
• Total spinal anesthesia or high spinal anesthesia
  due to inserting the epidural catheter (reported
  case)

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STUDY DESIGN

• This is a clinical study
• Inclusion criteria
• All patients had pelvic prolapsed requiring
  operation at HV Hospital
• Older patients (60 80 years old)
• May had concurrent diseases, cardiovascular
  diseases, liver diseases, and kidney diseases

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STUDY DESIGN

• Exclusion criteria
• Vertebral disease polio, vertebral deformity,
  vertebral malformation, cypho scoliosis
• Systemic infection, infection of the puncture
  site.
• Hematological disorders
• Severe anemia
• Heart failure
• Hepatic failure, renal failure

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STUDY DESIGN

• Sampling
• Accessible population vaginal hysrectomy caused
  by pelvic organ prolapsed, over 60 years old w/o
  concurrent diseases, treatment at HVH
• Study sample patients accept to enroll to the
  study
• Sample size at least 140 patients.
• Sampling randomized sample

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STUDY PROCEDURES

• 1. Materials
• Drugs Marcain 0.5, Lidocain 2, Fentanyl,
  Hypnovel, Ephedrine, fluid infusion
• CSE sets
• Vital Monitoring ECG, blood pressure, SpO2
• 2. Procedure
• Preparation of instruments
• CSE undergone
• 3. Procedure done in the Anesthesia Recover
  Department of Hung Vuong Hospital
• 4. Duration of study
• From 03/2004 to 12/2005

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POSITION FOR AN EPIDURAL
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TECHNIQUE OF CSE(1)

• Local infiltration
• Introduce the Tuohy needle at the puncture site
  L3 L4
• Attach the syringe
• Identify the epidural space by LOR
• Insert the spinal needle 27 through the Tuohy
  needle
• Look for the spinal liquid flow
• Inject the Marcain 0.5 1ml solution 25mcg
  Fentanyl
• Insert the catheter and fix it

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TECHNIQUE OF CSE(2)

• Return the patient on the back
• Follow up the pulse rate, blood pressure and
  assess the level of anesthesia every 5 minutes
• Inject through the catheter 2ml Lidocain 2
  (40mg) as catheter test dose if the hemodynamic
  condition remains stable.
• Close control of hemodynamic condition and assess
  analgesia level.
• After 30 minutes, repeat the bolus of Lidocaine
  2 (4 8ml) (80 160mg)

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TECHNIQUE OF CSE
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Advancing catheter into epidural space
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RESULTS (1)

• At the Department Anesthesia of Hung Vuong
  Hospital, from 03/2004 to 5/2006, there were 140
  old patients (60 80 years old) operated for
  genital utheral prolapse by low dose CSE
  technique.

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RESULTS (2)
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RESULTS (3)

• () Otherwise osteoporosis, hyperthyroid, fatty
  liver, asthma,
• Cardiovascular diseases hypertension (43.41),
  coronary insufficiency (33.33), mitral
  regurgitation (9.3)

Diabetes
tuberculosis
others
Cardiovascular diseases
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RESULTS (4)
healthy
3 diseases
2 diseases
1 disease
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HEMODYNAMIC CONDITION

• Volume of fluids infusion are used during
  operation

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HEMODYNAMIC CONDITION

• Mean pulse rates of the study group

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HEMODYNAMIC SITUATION (3)

• Increase pulse rates gt 10 versus previous
  value
• Decrease pulse rates lt 10 versus previous value
• Variation of pulse rates 10 ? little value

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HEMODYNAMIC SITUATION (4)

• Mean systolic and diastolic pressure

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HEMODYNAMIC SITUATION (5)

• Blood pressure decreases in 126 cases 10
  compared to previous value.
• 10 cases decrease 20 compared to previous value.
• Only 4 case had hypotension because BP decreased
  more than 30. It was resolved by ephedrine and
  fluid infusion.

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DURATION OF OPERATION
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AGES
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RESPIRATION CONDITION

• Change in respiratory frequency no patient
  experiencing dyspnea in 140 cases
• Change in SpO2 Oxygen supplied by mask with FiO2
  100, SpO2 98 100

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UNEXPECTED EFFECTS
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POSTOPERATIVE ANALGESIA

• Postoperative analgesia done by continuous
  epidural analgesia with 8ml Marcain 0.125
  1mcg/ml Fentanyl per hour
• Analgesia level more comfortable after operation
  (EVS 0)
• Sedation level alertness, no discomfort, good
  communicaton.
• No respiratory depression

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Postoperative urinary retension

• Foley catheter is kept about 3 postoperative days
  for vaginal anterior vault repair.
• Urinary retention 1 /140 cases may be for
  urinary infection

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CONCLUSIONS

• Providing the effect of analgesia by smallest
  dose of local anesthetic.
• Duration of operation assured by epidural
  anesthesia.
• Postoperative analgesia is more effective than
  administration of opiates and intravenous
  paracetamol
• Increasing epidural dose of Lidocaine may allow
  us to have safe and effective operations in cases
  of abdominal hysterectomy for high risk patients.

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THANK YOU FOR YOUR ATTENTION!