Combined spinal‐epidural as an alternative method of anaesthesia for a sigmoid‐colectomy

We would like to report the case of an 82-year-old woman who required a sigmoid colectomy for carcinoma of the rectum. She is an ex-smoker, living in a nursing home, with a past medical history of congestive cardiac failure, hypertension, chronic obstructive airways disease and osteoporosis. The osteoporosis contributed to severe kyphosis (Fig. 8) leaving her with poor lung function (Table 1). Her exercise tolerance was 10–20 m with a Zimmer frame and she required four pillows for orthopnoea. Special investigations showed mild mitral regurgitation with left ventricular hypertrophy on echocardiograph; small bilateral effusions on chest X-ray and an arterial blood gas showing type 1 respiratory failure. We were concerned that a general anaesthetic would contribute to further respiratory failure requiring prolonged intensive care management and ventilation. After discussion with patient and family we opted for a combined spinal–epidural technique. Using an aseptic technique, we used a needle through needle technique (27 g/16 g-touhy) at L2−3 interspace. The spinal injection was 3 ml of bupivacaine 0.5% with fentanyl 25 µg. The epidural comprised a mixture of 15 ml of lidocaine 1%, and 15 ml of bupivacaine 0.25% over a period of 3 h, which was give in boluses of 5 ml. An arterial cannula was inserted into a radial artery for accurate blood pressure and blood gas monitoring. The patient was positioned head up with three pillows and a break in the table and received oxygen 5 l.min−1 through a Hudson mask. The surgeons could access the surgical field but there was an understanding that if the splenic flexure needed to be mobilised we would have no alternative than to change to a general anaesthetic. The procedure lasted 2.5 h and the patient received 1 l of colloid and 1.5 l of crystalloid. The blood loss was approximately 700 ml. Although arterial blood gasses showed an increasing respiratory acidosis, it had corrected itself on arrival in intensive care (Table 2). The patient stayed in intensive care for 2 days receiving 2 units of blood and was mobilizing around the surgical ward with her Zimmer frame by day 5. She was discharged from hospital a fortnight later. We undertook a literature search and accessed one case [1] that drew some comparison to our case. A patient with severe multiple sclerosis had a sigmoid colectomy for a volvulus and received a spinal anaesthetic with a spinal catheter; diamorphine was used via this catheter postoperatively with a similar favourable outcome as ours. Although a sigmoid colectomy is synonymous with a general anaesthetic, with the possibility of an epidural for intra- and postoperative analgesia, we would like to put forward this case as an alternative technique to the above mentioned operation.

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