anesthesia for risky patient ASA III under spinal anesthesia

1. Anesthesia challenge
High Spinal Anesthesia and High Midline Incision for Abdominal surgery.
Can person with high cardiac risk disease go under high spinal anesthesia for high midline
abdominal surgery.
Dr.Iyad Abu Karsh MD. Chief of Anesthesia Department
Dr.Naser Redwan MD. Chief of Surgery Department
Dr.Akram Hussein M.D. Consultant G.A
DR.Hany Saleh M.D G.S
Summary
72 years old female patient with Acute Abdominal Pain, since three days with Co morbid
disease condition such as CHF,DM,AF,HTN, was admitted to OR. For high midline laparatomy
- A High spinal anesthesia was used, where in bupivicain 0.5% 2.5ml +DW2.5ml was used
The benefits of this technique, to avoid cardio respiratory depression under GA. From
anesthetic drugs, high sensation level block, hemodynamic stability, minimal amount of drugs
used, and ability to achieve the desired segmental level of anesthesia.
Key Word :-high spinal anesthesia, CHF, AF ,DM, spinal deformity.
Introduction
The preoperative management for patient with CHF for abdominal surgery is challenge for
anesthesia due to presence of co morbid disease unstable cardio respiratory status
-Anesthesia controversial to GA Regional.
-High spinal anesthesia is challenge method as regional anesthesia for abdominal surgery with
high midline incision.
-We used technique of high spinal anesthesia in some cases with multiple co morbid disease.
Case Report.
A 72 years old female patient, presented to surgery department in K.O. H in February 2015,
complaining of pain in the epigastric region since 3days, vomiting many times, fever,
Patient had DM treated Amaryl 3mg+Glucophage 500mg,HTN treated by amiloride 15mg+AF
digoxin 0.25mg CHF treated by lasix 40mg-convertien 10mg.
Patient was diagnosed as intestinal obstruction. CT waw done Mass under epigastric region
Investigation: -
CBC: Hb: 10.5gm/dl , HCT%: 33 , WBCs: 9,5 PLT: 114 K
Chemistry: FBS:298mg/dl,

2. Creatinine:1 mg/dl, Urea_:-39mg/dl
Other tests :Na 142mg/l -K4.1mmol/l Ca 10 mg/dl
PT 12 sec INR 100% PTT 45sec
Alat 174 IU/dl ALP 100 IU/dl
Preoperative management
Vital signs:
T37C° , Bp:140/75,
RR: 20/min, HR100/min
Clexan 80 mg sc/24
hr-
-NS 500ml IV /24hr
-
- Ranitidine 50 mg
IV/6hr
-ROCIEFEEN 1 g
IV/12hr
-CREBPANDAGE both
legs
Prepare 4 units
PRBCs-
Insulin scale--FLAGYL
500mg/8hR-
Anesthesia Plan :REGIONAL –HIGH
SPINAL
Prepare 4 units
FFP-
-AMIODARONE
150mg
In 100ml G5%
Intraoperative management
- Under full monitoring -ECG-HR-PLO2-BP
- Nasal O2 Canullea 5 L/min.
-& under full septic technique povidine 10%
- local anesthesia 1%-10 ml at level L2-L3
-Spinal Needle (black) G 22- pencil point
- Anesthesia Marcain 5%-2.5ml + DW 2.5ml
- After 5 min test of sensation to level sternum no sensation
- Skin incision -pain score 0
Duration of operation one hour
Postoperative management:
Recovery room for 15 min under monitoring
Then for surgical word patient after 5 days had been discharged safety without any problems
Discussion
Pereoperative management of patient with comorbid disease CHF, AF, DM, HTN, other is
challenge for anesthesia due to high incidence of morbidity and mortality due to
heamodynamic, metabolic heart kidney stress.
High spinal anesthesia is accepted approach for high medline abdominal incision for abdominal
surgery.

3. It include that difficult technique of high spinal anesthesia with high level of sensation or
motor block. The risk oaf hemodynamic or respiratory depression for patient with CHF.
The use of additional DW2.5ml to Bupivicain 0.5%2.5ml make high level of sensation block,
with Autonomic Motor block.
- Additional of 2.5ml DW. make Bupivicain Hypobaric relative to CSF .
Hypobaric Bupivicain makes hemodynamic no changes due to more sensation block and less
Autonomic motor block.
- The regional Anesthesetic agents are used for spinal anesthesia controversial, isobaric
bupivicain was initially preferred, Hypobaric was believed to result in drug stability position in
spinal cord.
To concluded, we reported the successful anesthesia management with high spinal technique
for patient with co morbid disease such as CHF ,AF, vertebral deformity, under go abdominal
laparatomy with high Medline incision.
Spinal anesthesia for high level sensation with bupivicain 0.5%-2.5ml+DW2.5ml was used to
benefits of high level sensation block, less Autonomic motor bloc, and hemodynamic stability.
This technique needs to be in the Anesthesia practice in high risk cardiac patient undergo
abdominal laparatomy with high midline incision.
Dr . IYAD AHMED ABU KARSH
CHIEF OF ANESTHESIA DEPARTEMNT
K.O.H
E-mail: iyasnopain@hotmail.co.il