Neuraxial Anesthesia in Major Abdominal Surgery
Jennifer Ranieri, BSN, RN, SRNA
University of Pennsylvania
Anticipated date of graduation: May 2015
Email address: ranierij@nursing.upenn.edu
Keywords: Pancreaticoduodenectomy, pain management, epidural analgesia, combined
general and epidural anesthesia, opioid
Patients undergoing extensive abdominal surgeries such as a pancreaticoduodenectomy,
or “Whipple” procedure, can be difficult for the anesthetist to manage due to surgical
manipulation and large incision. Incorporating neuraxial anesthesia into a general
anesthetic allows for a multimodal approach in treating pain. Epidural anesthesia is a
neuraxial technique that involves placement of a catheter into the epidural space for
intermittent or continuous local anesthetic administration.1 A hybrid anesthetic such as
combined general and epidural anesthesia may prove to have intraoperative and
postoperative benefits when compared to more traditional methods such as intravenous
(IV) opioids.
Case report
A 58-year-old female 154cm tall and weighing 108.6kg presented for a
pancreaticoduodenectomy for treatment of cancerous pancreatic tumors. Her medical
history included obesity, diabetes, hypertension, smoking, arthritis and deep vein
thrombosis. Her surgical history included placement of an inferior vena cava filter. Her
current medications included amlodipine, insulin, lisinopril, oxycodone- acetaminophen,
paroxetine and warfarin. Physical exam revealed obesity, decreased breath sounds and
jaundiced skin and sclera. One 18 gauge peripheral IV catheter was placed with lidocaine
2% local anesthesia in the preoperative area.
Premedication of midazolam 2 mg IV was given upon leaving the holding area.
Anesthetic induction included application of standard ASA monitors once patient arrived
in the operating room. Oxygen was applied via nasal cannula at 4L/min during placement
of an epidural catheter between the 9th and 10ththoracic vertebrae in the sitting position.
Fentanyl 100 mcg and propofol 60 mg IV were given during the epidural placement.
Following epidural placement, the patient was repositioned supine on the table and
preoxygenation was performed via facemask with 100% FiO2 with normal tidal volume
breathing for 6 minutes. General anesthesia was induced with IV boluses of propofol 200
mg, 2% lidocaine 100 mg, and fentanyl 100 mcg. Successful mask ventilation was
established and rocuronium 50 mg IV was given. Direct laryngoscopy was performed
and a 7.0mm endotracheal tube was placed. Endotracheal tube confirmation was
established with positive end-tidal carbon dioxide (ETCO2) and bilateral breath sounds.
General anesthesia was maintained with sevoflurane 2% inspired concentration with
2L/min of O2. Mechanical ventilation was initiated with volume-controlled ventilation to
maintain an ETCO2 between 29-33mmHg.
After induction, a left radial arterial line was placed and a right internal jugular triple
lumen central line was placed. An additional 16 gauge peripheral IV was also placed.
Intraoperative IV medications included an additional rocuronium 50 mg, labetalol 25 mg,
insulin aspart 10U, metronidazole 500 mg and levofloxacin 500mg. The patient received
1150ml of crystalloid solution with 760ml urine output and an estimated blood loss of
200ml.
The epidural was test-dosed with lidocaine 1.5% with epinephrine 1:200,000 3ml thirty
minutes after incision. Bupivacaine 0.25% 5ml was administered via epidural injection.
Total IV opioids included fentanyl 300 mcg given in 50-100 mcg doses throughout the
procedure as well as hydromorphone 1mg.
Emergence from anesthesia began as the procedure came to an end. The sevoflurane was
titrated off. Neuromuscular blockade was antagonized with neostigmine 5 mg IV and
glycopyrrolate 0.6 mg IV with a resulting train of four 4/4 with sustained tetany.
Nitroglycerine 50 mcg IV was given for a systolic blood pressure above 200mmHg.
Ondansetron 4 mg IV was given. After obtaining spontaneous tidal volumes greater than
5ml/kg with a spontaneous respiratory rate greater than 8 breaths a minute, the patient
demonstrated a five second head lift and followed verbal commands. The airway was
suctioned and the endotracheal tube was removed with positive pressure. The patient was
placed on 4L/min of oxygen via nasal cannula immediately following extubation and had
no complaints of pain.
Discussion
Intraoperative and postoperative pain management can be especially complicated for
patients undergoing large open abdominal procedures, such as a
pancreaticoduodenectomy. The large amount of pain patients experience during and after
these procedures can elicit great quantities of opioid administration in an attempt to
control severe pain. Combining general anesthesia and neuraxial anesthesia, such as with
epidural catheter placement and utilization, is a valuable option in implementing a
balanced anesthetic as well as incorporating multimodal analgesia. Additional advantages
of providing analgesia via an epidural route have been demonstrated such as diminishing
the sympathetic response triggered by surgery, facilitation of mobility and decreasing
incidence of ileus.1
Opioid medications are a cornerstone of effective anesthesia care due to their ability to
provide analgesia, one of the tenets describing the goals of anesthesia. Opioid drugs exert
their effects by binding to mu, kappa, and delta opioid receptors.2 These receptors are
located throughout the body in central and peripheral sites.2 Central sites include the
brain and spinal cord and peripheral sites include the blood vessels, gastrointestinal tract,
heart, lungs, immune tissue, and genitourinary tract.2
These receptors are responsible for the analgesic effect of both intravenous and epidural
administered opioids, but have resulting negative side effects. Such side effects include
bradycardia, sedation, nausea and vomiting, skeletal muscle rigidity, pruritus, histamine
release, constipation and urinary retention.1,2 Patients receiving intravenous morphine
experience a higher incidence of adverse effects such as sedation and hallucinations when
compared to patient’s receiving epidural analgesia.3 Combining general anesthesia and
local anesthetic administration via an epidural catheter reduces the amount of intravenous
opioid medication for upper abdominal surgery,4 thus minimizing the incidence or
severity of these unwanted side effects.
One of the most concerning side effects of opioid administration is respiratory
depression. Patients receiving intravenous morphine exhibit a higher incidence of
respiratory depression.3 This adverse effect directly impacts anesthetic management due
to prolonged intubation and mechanical ventilation as well as higher incidences of postoperative respiratory failure. Epidural anesthesia provides a significant decrease in the
incidence of respiratory failure in high-risk patients undergoing major abdominal surgery
with combined general and epidural anesthesia.5 Time to tracheal extubation is reduced
up to 48% when utilizing combined epidural and general anesthesia.6,7 Decreased
respiratory depression and prompt tracheal extubation reduces hospital stay and decreases
need of intensive care management.7
It can be quite challenging to manage postoperative pain in patients who have large
incisions and experience extensive intra-abdominal surgical manipulation. The decision
to place an epidural catheter in the preoperative period allows for lower post-operative
visual analog pain scales,6 particularly when rating pain with movement and coughing.7
Subsequently, less morphine is consumed in the first 24 hours immediately following
surgery when undergoing general anesthesia with combined epidural anesthesia.6 This is
an important factor for selecting an effective postoperative analgesic methodology to
optimize mobility and pulmonary hygiene.
Organ system functionality is of the utmost importance in all post-operative patients.
Anesthetic selection for an extensive surgery on the gastrointestinal tract such as a
Whipple procedure requires special consideration to prevent gastrointestinal
complications, which epidurals prove to avoid.7 Epidural analgesia also allows for
decreased incidences of cardiac events such as myocardial infarction, ischemia, and
angina as well as significantly decreased incidences of renal insufficiency. Optimization
of cardiac, renal, gastrointestinal and pulmonary functionality are critical in those
recovering from the Whipple procedure, which historically maintains a high morbidity
and mortality.3
In this particular case, we can see several of the aforementioned benefits of combining
epidural analgesia with general anesthesia. Minimizing opioid administration in such a
major surgical operation is of noteworthy significance, particularly when considering the
management of side effects. Adequate ventilation, oxygenation and the preservation of
pulmonary function are crucial aspects of implementing a successful anesthetic and
cannot be limited to the intraoperative period. This is demonstrated by the ability of the
patient to meet extubation criteria immediately following the Whipple procedure. The
placement and utilization of epidural catheters also allows extremely efficacious
analgesia while preserving global body systems. Adequate pain control upon emergence
is satisfying for the patient and the anesthetist, but the ability to also preserve multisystem organ functionality while transitioning the patient safely into the recovery period
demonstrates achievement of a remarkable anesthetic goal.
References
1. Butterworth JF, Mackey DC, Wasnick JD. Morgan and Mikhail’s Clinical
Anesthesiology. 5th ed. New York: The McGraw-Hill Companies; 2013:937-973.
2. Nagelhout, JJ, Plaus KL. Nurse Anesthesia. 5th Ed. St. Louis: Elsevier; 2014:149-152,
461-463, 1070-1098.
3. Marandola M, Cilli T, Alessandri F, et al. Perioperative management in patients
undergoing pancreatic surgery: the anesthesiologist's point of view. Transplantation P.
2008;40(4),1195-1199. DOI: http://dx.doi.org/10.1016/j.transproceed.2008.03.114
4. Li Y, Zhu S, Yan M. Combined general/epidural anesthesia (ropivacaine 0.375%)
versus general anesthesia for upper abdominal surgery. Anesth Analg. 2008;106(5),15621565. DOI: 10.1213/ane.0b013e31816d1976
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major surgery: a randomised trial. Lancet. 2002;359(9314),1276-1282. DOI:
10.1016/S0140-6736(02)08266-1
6. Guay J. The benefits of adding epidural analgesia to general anesthesia: a
metaanalysis. J Anesth. 2006;20(4),335-340. DOI: 10.1007/s00540-006-0423-8
7. Nishimori M, Low JHS, Zheng H, Ballantyne JC. Epidural pain relief versus systemic
opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev.
2012;(7),1-85. Published July 11, 2012. Accessed June 14th, 2014. DOI:
10.1002/14651858.CD005059.pub3
Mentor: Kelly L. Wiltse Nicely, PhD, CRNA
wiltse@nursing.upenn.edu