THORACIC EPIDURAL ANESTHESIA ENHANCE RECOVERY AFTER

EMERGENCY LAPARATOMY IN COVID-19: A CASE REPORT

Aidyl Fitrisyah1, Andre Saputra2, Julius Santoso2, Stevanus Eliansyah

Handrawan2.
1
Department of Anesthesiology and Intensive Therapy, Faculty of Medicine,
Universitas Sriwijaya, Indonesia
2
Resident of Anesthesiology and Intensive Therapy, Faculty of Medicine,
Universitas Sriwijaya, Indonesia
* Researchers e-mail correspondence:

Abstract
Introduction: Laparatomy exploration has been successfully performed using
thoracic epidural anesthesia alone in emergency patient with probable covid-19.
We describe this case by using Bromage’s Formula to calculate the require doses
for a satisfactory segmental block
Case Report: A patient was diagnosed as peritonitis diffuse with suspicious
viscus organ perforation underwent open exploration laparotomy. She received
thoracic epidural anaesthesia alone. An 18G touhy needle was introduced at
T11/12 intervertebral space and the tip of catheter was advanced 4cm cephalad
beyond tip of needle (T9/10). Epidural Anesthesia was established with 0.75%
ropivacaine. The used doses were calculated 1-2 mL per segment.
Conclution : thoracic epidural anesthesia provides optimal perioperative
anaesthesia and analgesia after thoracic and major abdominal surgery and
decreases postoperative morbidity and mortality, mainly blocking sympathetic
nerve fibers. An experience operator can use it as the sole anesthetic technique in
selective cooperative patients. The Bromage’s formula can be useful clinical aid
for the anaesthetist in the described settings.
Keywords: Thoracic epidural anesthesia, Laparotomy, COVID-19
Introduction
Thoracic Epidural Anaesthesia (TEA) is commonly used for anesthesia procedure.
The use of TEA can reduce the incidence of myocardial infarction in the
perioperative period. After thoracotomy and major abdominal surgery, TEA
results in pain free ventilation and increases the abdominal ventilation, resulting in
a lower incidence of postoperative complications. Moreover, epidural anaesthesia
blocks the nerve fibers innervating the mesenterial blood vessels and improves the
mucosal blood flow leading to a lower rate of anastomosis dehiscences after
abdominal surgery. Finally, TEA improves the immune response, increases
wound tissue oxygen tension. These effects have a strong impact on the quality of
life. In spite of these features, there is a paucity of data in the literature regarding
this technique being performed under epidural anaesthesia alone, especially in
patients who are deemed at high risk for general anesthesia. There are even less
data about the volume and concentrations of local anaesthetic to be used in this
settings.1
Coronavirus disease 19 (COVID-19) has presented challenges to healthcare
systems around the world and will continue to do so for months and perhaps
years. The threats that the disease poses to both patients and healthcare workers
have changed medical practice, but these changes can offer opportunity to those
with subspecialty interests in areas such as regional anaesthesia. Indeed, the
European and American Societies of Regional Anaesthesia have produced joint
COVID-19 recommended that regional anaesthesia should be preferred over
general anaesthesia whenever possible, and practice recommendations for regional
anaesthesia during the pandemic have subsequently been published. Other
perceived advantages of regional anaesthesia during the COVID-19 pandemic
may include: a reduction in aerosol-generating procedures (AGPs) and thereby
both increased safety and a saving in the time, resource and financial costs of
personal protective equipment (PPE), preservation of immune function when
compared with general anaesthesia, improved postoperative analgesia minimising
direct contact with care givers, and earlier discharge.  Airway manipulation is
associated with some of the highest rates of coronavirus transmission, and it is
recognised that minimising AGPs is desirable. SARS-CoV-2 is primarily spread
via respiratory droplets and fomite transmission. Droplet spread is limited by
gravity to <2 m, whereas AGPs lead to more distant spread of the virus, which in
turn also remains airborne for longer. Coughing and sneezing are considered to be
droplet-generating, but there is a suggestion that these, or even talking and
breathing, may also generate aerosols, which is clearly important in an awake
patient for whom droplet precautions alone would be used.2

Case Report
A 62-year-old female patient underwent emergency exploration laparotomy under
awake epidural anesthesia. She was classified as ASA grade IV due to : Sepsis
with sequential organ failure assessment (SOFA) score 2, Pneumonia-probable
COVID-19 (emerging infectious disease EID team), anemia (Hb= 7.8),
hypoalbuminemia (2.2), hyperglycemia (BSS = 517 mg/dL). His past medical
notes included history of chronic pain on knees treated with analgesic and
traditional herbs. Because of the high anaesthetic risk, and limited isolation ICU,
she was delayed for 2 days to perform the surgery.
A risk-benefit analysis was made pre-operatively and we decided to proceed to
open exploration laparotomy under awake thoracic epidural anaesthesia. We
obtained the patients’ consents to complete the surgical performance under
exclusive regional anaesthesia. We obtained written consents from the patients for
a possible publication of their data. Continuous pulse oximetry, blood pressure
cuff and electrocardiographic monitoring were performed. The patients were
placed in seated position. A nasogastric tube was inserted. For epidural
anaesthesia, a midline approach was used under complete aseptic preparation.
Local anaesthesia (2% lidocaine 5 ml was injected into the skin. An 18-gauge
Tuohy needle was introduced at T11/T12 intervertebral space. The epidural space
was identified using the loss of resistance technique and an epidural catheter was
passed through the needle. The tip of the catheter was advanced 4 cm cephalad
beyond the tip of the needle (T9/T10) and secured with a steril dressing.
Aspiration test for subarachnoid and intravascular placement was negative. A test
dose of 2% lidocaine 1 ml, 2% Pehacain 1,2 ml, total 3 ml with normal saline was
administrated through the epidural catheter with no change noted in the heart rate,
blood pressure, or sensorimotor examination.
Neural blockade from T4 to L1 was required for this case, 9 segments of thoracal,
and 1 segment of Lumbal. We used 11 mL of 0.75 ropivacaine in this case. Ten
minutes after the bolus injection, a sensory block to temperature extending from
T4 to L1 was achieved. postoperative pain was controlled by continuous thoracic
epidural infusion of Ropivacaine 0.25% at 5mL/h. The patients were kept
sufficiently alert so as to protect the airways and allow them to answer questions,
but sedated enough in order to maintain their protective reflexes. The patient
hemodynamic were stable throughout the procedures (Figure 1).

Intraoperative Hemodynamic
140
120
100
80
60
40
20
0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
Times (minutes)

Systolic Diastolic Heart Rate

RR SpO2

Figure 1. Intraoperative Hemodynamic Status

The surgery was performed without complications. Three hours later the patients
were transferred to the isolation ward (figure 2) with stable haemodynamic status
and complete neurologic examination. Epidural analgesia was maintained through
the following 24 hours. Back pain, numbness, paresthesia, or motor weakness was
not present and the patient was comfortable and pain-free during this time. A 10-
cm visual analogue pain scale (VAS) was employed to assess for analgesic
requirements and the score always resulted to be less than 2 cm. Another
postoperative complication such as nausea, vomiting, and gastrointestinal
paralysis. The patient length of stay was 2 days in total.

Figure 2. Patients in isolation ward

Discussion
The case series describe open exploration laparotomy performed under TEA in
high risk patient without complication. In addition to changes to mucociliary
transport associated with anesthetic agents, abdominal surgery–particularly upper
abdominal surgery-is associated in normal individuals with adverse effects on
respiratory mechanics such as functional Residual Capacity (FRC), Vital Capacity
(VC), Tidal Volume (TV), and closing volume. Because mucociliary escalator is
an important pulmonary defense mechanism against infection, general anaesthesia
may be deleterious to the patient with COPD undergoing surgical procedure. The
goal of anaesthesia management in these patients should include avoidance of
anaesthetics that depress mucociliary transport, provision of postoperative pain
relief adequate to prevent deterioration of respiratory mechanics, and leading to
early mobilization of patient. Moreover, epidural anaesthesia blocks the fibers
innervating the mesenterial blood vessels and improves the mucosal blood flow,
even under conditions of reduced perfusion pressure. Finally, TEA improves the
immuneresponse, increases wound tissue oxygen tension allowing a better health-
related quality of life.
Sepsius and septic shock could induce macro and microcirculation dysfunction.
Resuscitation of global hemodynamic and oxygen not correlated to tissue dysoxia.
This dysfunction closely related to inflammatory mediator and microemboli that
could alter the microvascular autoregulation and increase oxygen shunting4.
Thoracic epidural anesthesia induce better redistribution of blood toward the
gastrointestinal microcirculation. Gastrointestinal and hepatic perfusion is
regulated by sympathetic and parasympathetic nerves thus TEA could improve
perfusion in laparotomy procedure5. This patients also have sepsis, previous study
by Lauer et al, shown that TEA could improve pulmonary endothelial integritiy in
hyperdynamic sepsis6. COVID-19 could induce sepsis with pulmonary as the
main target so TEA could be considered to improve pulmonary endothelial
integrity.
Postoperatively this patient didn’t have complications such as pain,
gastrointestinal paralysis, nausea and vomiting. Cochrane systematic reviews in
2017 also shown that TEA could reduce postoperative pain at 24 hours after
surgery, vomiting and gastrointestinal anastomotic leak. Length of hospital stay
for an open surgery also reduced. Epidural anesthesia mechanism for better
postoperative effect may be caused by reduced opioid adiminstration and
sympathetic gut innervation blockade. This method equivalent to opioid pain
relieve that makes TEA better alternative than opioid administration 7. This
benefits have better outcomes in patients with a high risk of complications such as
pulmonary complication, bowel recovery and postoperative myocardial
infarction8.
On the basis of our experience we believe that thoracic epidural anaesthesia is a
valid alternative for high-risk surgical patients undergoing to upper abdominal
surgery. General anesthesia requiring airway intervention may exacerbate
COVID-19 pneumonia, and aerosol generation during airway intervention risks
COVID-19 transmission to medical staff. regional anesthesia is not an aerosol-
generating procedure.  A history of respiratory infection within a month is
reported to be an independent predictor of risk for postoperative pulmonary
complications. Thus, nonurgent surgeries in patients with respiratory infections,
including COVID-19, should be postponed and rescheduled after infection
treatment. In addition, general anesthesia requiring airway intervention has a
higher risk of perioperative pulmonary complications than regional anesthesia. 2
Considering the intrinsic limitations of a case report, we realize that further
studies, such as randomized clinical trials, are warrant to better establish the role
and benefits of TEA as a sole anaesthetic technique in patients undergoing upper
abdominal surgery. 1

Reference

1. Consani G, Nunziata A, Amorese G, Boggi U. Thoracic epidural

anaesthesia in awake upper abdominal surgery: safety/validity of
bromage’s formula. J Anesth Clin Res 2014.5:3.
2. Macfarlane AJR, Griffiths WH, Pawa A. Regional. Regional anesthesia
and covid-19: first choice at last?. Br J Anaesth.2020; 125(3): 243-247.
3. Hotta K. Regional anesthesia in the time of covid-19: a mini review. J
Anesth.2020; 25:1-4.
4. Siniscalchi A, Gamberini L, Laici C, Bardi T, Faenza S. Thoracic epidural
anesthesia: effects on splanchnic circulation and implications in anesthesia
and intensive care. World J Crit Med. 2015;4(1):89-104.
5. Bachmann KA, Trepte CJC, Tomkotter L, Hinsch A, Stork J, Bregmann
W, et al. Effects of thoracic epidural anesthesia on survival and
microcirculation in severe acute pancreatitis: a randomized experimental
trial. Critical Care. 2013;17:1-12
6. Lauer S, Freise H, Westphal M, Zarbock A, Fobker M, Van Aken HK,
Sielenkamper AW, Fischer LG: Thoracic epidural anesthesia
timedependently modulates pulmonary endothelial dysfunction in septic
rats. Crit Care 2009, 13:R109.
7. Guay J, Nishimori M, KoppS. Epidural local anesthetics versus opioid-
based analgesic regimens for postoperative gastrointestinal paralysis,
 vomiting and pain after abdominal surgery (review). Cochrane Library
2017; 1-229.
8. Salicath JH, Yeoh ECY, Bennett MH. Epidural analgesia versus patient-
controlled intravenous analgesia for pain following intra-abdominal
surgery in adults (review). Cochrane Library 2018;1-145.