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CASE REPORT
Year : 2022  |  Volume : 8  |  Issue : 3  |  Page : 281-284

Paraplegic Patient for Lower Limb Surgery: Monitored Anesthesia Care (MAC) as an Alternative Approach


Department of Anaesthesia & Intensive Care, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi, India

Date of Submission15-Aug-2022
Date of Decision26-Sep-2022
Date of Acceptance16-Oct-2022
Date of Web Publication07-Dec-2022

Correspondence Address:
Mousumi Saha
Department of Anesthesia & Intensive Care, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi-110002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_49_22

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  Abstract 


Patients with spinal cord injury 4–8 weeks back presenting for non-spinal elective surgery, present a unique challenge to the anesthesiologist. The perioperative concerns include potential for perioperative autonomic hypereflexia, muscle spasms, respiratory inadequacy, controversies regarding the use of muscle relaxants and opioids as well as medico-legal and technical issues associated with administration of regional anesthesia. Both general as well as regional anesthesia has been used for surgery on the insensate part below the level of injury with variable success but no standard definitive anesthetic management is recommended. We present our case series of monitored anesthesia care administration in paraplegic patients who presented for lower limb surgeries.

Keywords: Anesthesia, monitored anesthesia care, MAC, non-spinal surgery, paraplegia


How to cite this article:
Wadhwa B, Saxena KN, Saha M. Paraplegic Patient for Lower Limb Surgery: Monitored Anesthesia Care (MAC) as an Alternative Approach. MAMC J Med Sci 2022;8:281-4

How to cite this URL:
Wadhwa B, Saxena KN, Saha M. Paraplegic Patient for Lower Limb Surgery: Monitored Anesthesia Care (MAC) as an Alternative Approach. MAMC J Med Sci [serial online] 2022 [cited 2023 Feb 1];8:281-4. Available from: https://www.mamcjms.in/text.asp?2022/8/3/281/362897




  Introduction Top


Anesthesia for non-spinal surgery below the level of injury in a patient with chronic spinal cord trauma presents unique considerations. The understanding of pathophysiology of the chronic spinal cord injury (SCI) is essential for the perioperative management and the concerns include potential for autonomic dysreflexia, involuntary muscle spasms, and incomplete sensory loss which may necessitate need for anesthesia. Till date, there is no definitive consensus regarding the anesthetic management of such cases and both general anesthesia and regional anesthesia have been used with variable success.[1]

Controversies regarding use of muscle relaxants and opioids as well as a high rate of respiratory complications make general anesthesia challenging while regional anesthesia is usually avoided due to technical difficulty in administration and medico legal concerns in SCI patients.[2],[3] Monitored anesthesia care (MAC) with or without sedation may be a safe and suitable alternative for surgery below the level injury in paraplegic patients.[4],[5]

We report our case series of paraplegic patients with chronic SCI who underwent lower limb surgery under MAC with favorable outcome.


  Case Series Top


We report the anesthetic management of eight patients with varying levels of SCI and paraplegia who underwent lower limb surgery under MAC.The first being a 36 year old, ASA grade II, male patient with traumatic paraplegia (T6 level) who presented for interlocking nailing of a 2 weeks old fracture right shaft femur. Detailed neurological examination revealed a complete sensory-motor loss (both deep and superficial touch sensation) below T6 level with bladder and bowel involvement. The patient gave a history of productive cough with coarse crepitation in bilateral lower zones. Rest of the systemic examination was unremarkable. An attempt was made to optimize the chest condition through nebulization, breathing exercises, and mucolytics but was limited by the patient‘s inability to cough effectively. The patient had previously undergone external fixation in the emergency without any anesthesia. In view of complete sensory-motor block, a co-existing poor chest condition and encouraged by the uneventful external fixation without anesthesia, we decided to take up the case under monitored anesthesia care. Preoperative sedation was withheld keeping in mind the high level of motor deficit and the poor chest condition. In the operating room, standard monitors were applied (SpO2, NIBP, ECG, temperature), two large bore IV lines established and all standard anesthesia drugs, emergency drugs, and resuscitation equipment were kept ready. The team was ready with all preparations for providing general anesthesia (GA), in the event of any pain, discomfort, or signs of autonomic dysreflexia during the course of surgery. Vigilant monitoring was observed throughout the perioperative period. The patient did not complain of pain at any time during the surgery or in the postoperative period. There was no significant change in the pulse rate, but the blood pressure fluctuated to lower levels on a few occasions. This was accompanied largely with the change in position and with the blood loss that occurred with the reaming of the femur. The fall in blood pressure responded well to fast IV fluids administration each time. No vasopressors were required at any time and the surgery proceeded uneventfully. The monitoring continued in the postoperative period and no change was observed in any of the parameters at any point of time. Having successfully conducted this case under MAC, we were encouraged to follow the same technique in the subsequent patients who came to us. [Table 1] details the remaining seven patients who came to us for various lower limb orthopedic procedures. Patient no 4 with SCI at T-6 with hypertension and diabetes complained of discomfort and a stretching sensation during the surgery for which injection fentanyl 50 mcg IV was administered and the patient became comfortable thereafter [Table 1] and [Table 2]. Infrequent muscle spasms were observed in patient no. 3 and 7 which responded to 0.5 mg IV midazolam. The vitals were maintained throughout the perioperative period and there was no evidence of respiratory depression in any of the patients [Table 2].
Table 1 Demographic parameters with extent of SCI and surgeries with perioperative events

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Table 2 Extent of SCI with perioperative events and requirement of sedation and analgesia

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  Discussion Top


In the paraplegic patients with chronic SCI, non-spinal surgery below the level of injury can pose a unique challenge to the anesthesiologist. Although there is usually complete sensory motor loss below the level of injury, concerns of autonomic dysreflexia (ADR), muscle spasms, and incomplete sensory loss may lead to requirement of anesthesia in these patients. The anesthetic considerations include the prevention and management of perioperative ADR, hypotension, respiratory inadequacy, bradycardia, problems with muscle relaxant, and opioid use in a paraplegic as well as the technical difficulties encountered with administration of regional anesthesia. Further, there is a significant incidence of pulmonary complications and avoidance of general anesthesia may reduce the morbidity and mortality.[1],[4],[6] Monitored anesthesia care may provide a suitable alternative to the management of these patients. The existing literature pertaining to these cases is limited and is mostly related to obstetrics and urology.

All the patients in our case series had complete sensory and motor loss so our main concerns were of precipitation of ADR and intraoperative muscle spasms. ADR is a potentially life-threatening hypertensive condition with a reported incidence of 85% in patients with chronic SCI above the level of splanchnic outflow (usually above T6).[7],[8] The incidence is greater with complete and higher level lesions, during urological surgeries and in patients with a past history of ADR either during surgery or daily activities.[1] The precipitating factors are afferent stimuli below the level of injury and include bladder distension, uterine contractions during labor and surgical procedures involving pelvic organs or lower extremities.[7] Marked hypertension is the most prominent feature accompanied by headache, flushing, pupillary dilatation, cardiac dysrhythmias, or bradycardia with piloerection and sweating below the level of lesion and vasodilatation with flushing above the level of lesion.[5],[6],[9] Perioperative ADR can have devastating consequences and its prevention a great concerns to the anesthesiologist.

The various RA techniques used include the administration of epidural block,[10] combined spinal epidural anesthesia,[11] and sub-arachnoid block.[12] SAB is a widely accepted technique and low doses of 1.5 to 2.0 mL of hyperbaric Bupivacaine are usually administered.[6] Epidural anesthesia has been demonstrated to be effective in reducing ADR in laboring women. However, it is less reliable for other procedures.[4] The advantages notwithstanding, most anesthesiologist are hesitant to administer central neuraxial block in a patient with an unstable or a recent neurological injury. Technical difficulties due to traction and immobilization, anatomical deformity, spasticity, contractures would not only make administration of block difficult but also prone to complications.[4],[6] There are other valid concerns regarding the assessment of block, efficacy, and safety of neuraxial anesthesia in SCI.[13] While the motor block can be assessed by change in muscle tone from spastic to flaccid paralysis, it is difficult to ascertain the sensory level achieved with a pre-existing sensory-motor loss and a high index of suspicion is required for detection of total spinal block. Further there are medico legal concerns of administration of central neuraxial block (CNB) i.e subarachnoid and epidural anaesthesia in patients with SCI.

These concerns have led many an anesthesiologists to prefer GA in such patients. GA is effective in prevention of ADR and control of muscle spasm and ADR but the associated hypotension and respiratory dysfunction is a concern.[4] Yoo et al. have reported an exaggerated hemodynamic response to laryngoscopy and intubation in patients with complete SCI.[14] The use of muscle relaxants has its own set of problems. Severe hyperkalemia, even leading to cardiac arrest with use of succinylcholine and an increased sensitivity to the non-depolarizing muscle relaxants leading to prolongation of the block has been reported in paraplegics.[1] These all may also predispose the patient to the need for postoperative ventilation as the patient already has a high level of motor deficit.[6]

Various authors have reported a successful outcome with MAC in these patients. Hambly et al. had conducted a prospective survey on 515 paraplegic patients wherein 103 patients received standby anesthesia services under monitoring but the study did not provide the details of the intraoperative hemodynamic changes. They concluded that, paraplegic patients with low, complete lesions, undergoing surgery below the level of injury, may safely do so without anesthesia provided there is no history of ADR or troublesome spasms.[1] Vaidyanathan et al. reported ADR in three tetraplegic patients who underwent urological procedures without anesthesia and recommended that with lesions above T-6, nifedipine 10 mg should be given sublingually prior to cystoscopy to prevent increase in blood pressure due to ADR if taken up under MAC.[15] In another case report, Singh et al. reported a successful outcome in a 25-year-old paraplegic with cervical cord edema and T-11 sensory level who underwent intramedullary nailing under MAC with low dose propofol infusion to prevent triggering of ADR.[5] Recently Lee successfully administered dexmedetomidine for MAC in a 66-year-old male with chronic SCI at T7 level for cystolithotomy without anesthesia.[16]

In our patients, the neurological examination was suggestive of a complete spinal cord injury. All the patients had complete sensory loss with no pain perception and were unlikely to experience pain during surgery. There were no episodes suggestive of ADR in the preoperative period. In light of the above argument, we decided to take up the cases under MAC. Since, episodes of ADR are usually brief, self-limiting, and easily amenable to medical treatment (with some exceptions), we felt that there was no need for GA or RA as a pre-emptive measure for prevention of ADR. Further, there are no predictors for triggers of ADR and it can occur anytime, even with mild non noxious stimuli such as bladder retention, erection, pain, pressure sores etc.,[4] we felt that administering GA or RA is not the answer for prevention of ADR at all times and it is perhaps a better option to institute vigilant monitoring throughout the perioperative period with appropriate and timely management of ADR. In our case series, we had kept ready all measures for management of ADR and to administer GA in case the patient complained of pain at any time; however, these were not required.


  Conclusion Top


Although the literature available is too little to evaluate the relative risks of any one technique, we suggest that MAC may also be considered a suitable alternative approach for management of non-spinal surgeries below the level of injury in a paraplegic patient, provided there is adequate back up of the emergency drugs, equipment, and qualified anesthesiologist. Compliant patients with infrequent mild muscle spasms and no history of ADR are suitable candidates for surgery under MAC.

Authors’ contribution

Concept and design of study or acquisition of data or analysis and interpretation of data: Bharti Wadhwa, Kirti N. Saxena, Mousumi Saha. Drafting the article or revising it critically for important intellectual content: Bharti Wadhwa, Kirti N. Saxena, Mousumi Saha. Final approval of the version to be published: Bharti Wadhwa, Kirti N. Saxena, Mousumi Saha

Acknowledgment

To the residents of Department of anesthesia and Department of Orthopedics and technical OT staffs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hambly PR, Martin B. Anaesthesia for chronic spinal cord lesions. Anaesthesia 1998;53:273-89.  Back to cited text no. 1
    
2.
Winslow C, Rozovsky J. Effect of spinal cord injury on the respiratory system. Am J Phys Med Rehabil 2003;82:803-14.  Back to cited text no. 2
    
3.
Ball PA. Critical care of spinal cord injury. Spine 2001;26:S27-30.  Back to cited text no. 3
    
4.
Kanonidou Z. Anaesthesia for chronic spinal cord lesions. Hippokratia 2006;10:28-31.  Back to cited text no. 4
    
5.
Singh J, Singh M, Srivastava M, Kapoor D. Is monitored anesthesia care (MAC) for lower limb orthopaedic surgery in cervical cord injured patients adequate? Anaesth, Pain Intens Care 2015;19:94-5.  Back to cited text no. 5
    
6.
Petsas A, Drake J. Perioperative management for patients with a chronic spinal cord injury. BJA Educ 2015;15:123-30.  Back to cited text no. 6
    
7.
Leão P, Figueiredo P. Autonomic hyperreflexia after spinal cord injury managed successfully with intravenous lidocaine: a case report. Patient Saf Surg 2016;10:10.  Back to cited text no. 7
    
8.
Yoo KY, Jeong CW, Kim SJ et al. Remifentanil decreases sevoflurane requirements to block autonomic hyperreflexia during transurethral litholapaxy in patients with high complete spinal cord injury. Anesth Analg 2011;112:191.  Back to cited text no. 8
    
9.
Krassioukov AV, Furlan JC, Fehlings MG. Autonomic dysreflexia in acute spinal cord injury: an under-recognized clinical entity. J Neurotrauma 2003;20:707-16.  Back to cited text no. 9
    
10.
Katz VL, Thorp JM Jr, Cefalo RC. Epidural analgesia and autonomic hyperreflexia: a case report. Am J Obstet Gynecol. 1990;162:471-2.  Back to cited text no. 10
    
11.
Eldridge AJ, Kipling M, Smith JW. Anaesthetic management of a woman who became paraplegic at 22 weeks’ gestation after a spontaneous spinal cord hemorrhage secondary to a presumed arteriovenous malformation. Br J Anaesth 1998;81:976-8.  Back to cited text no. 11
    
12.
Amzallag M. Autonomic hypereflexia. Int Anaesthesiol Clin 1993;31:87-102.  Back to cited text no. 12
    
13.
Jones BP, Milliken BC, Penning DH. Anesthesia for Cesarean section in a patient with paraplegia resulting from tumour metastases to spinal cord. Can J Anesth 2000;47:1122-8.  Back to cited text no. 13
    
14.
Yoo KY, Lee JU, Kim HS et al. Hemodynamic and catecholamine responses to laryngoscopy and tracheal intubation in patients with complete spinal cord injuries. Anaesthesiology 2001;95:647-51.  Back to cited text no. 14
    
15.
Vaidyanathan S, Soni B, Selmi F et al. Are urological procedures in tetraplegic patients safely performed without anaesthesia? a report of three cases. Patient Saf Surg 2012;6:3.  Back to cited text no. 15
    
16.
Lee KH. Dexmedetomidine for chronic spinal cord injured patient. J Anesth 2014;28:953.  Back to cited text no. 16
    



 
 
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