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Correspondence |
Boston, Massachusetts
To the Editor:
McDonald cervical cerclage is an obstetric outpatient procedure in the lithotomy position frequently performed under spinal anesthesia (SA). Recently, low-dose SA techniques facilitating intraoperative hemodynamic stability and fast recovery have been described for this and other outpatient procedures.1–3 However, undesirable outcomes of SA include transient neurologic symptoms (TNS) from local anesthetic toxicity particularly for procedures in the lithotomy position4,5 and nausea and pruritus from adjuvant intrathecal opioids.1 Low-dose, or differential epidural anesthesia has not been described for McDonald cerclage as an alternative technique. A healthy 41-yr-old female, gravida 2 para 0, presented for the above procedure at 13 5/7 weeks gestation. Based on her prior anesthetic experience she requested regional anesthesia that would provide a gradual onset and minimal motor blockade. After initiation of electrocardiogram, non-invasive blood pressure and oxygen saturation monitoring in the operating room an 18-G epidural catheter was placed in the L 3–4 interspace. A negative test dose of 3 mL of 0.125% bupivacaine with epinephrine 1:200,000 was followed by incremental epidural administration of a total of 20 mL of bupivacaine 0.125% with 50 µg of fentanyl added to the first 10 mL of solution. A sensory level to T4 by cold sensation was apparent at 15 min. During placement of the epidural catheter and the subsequent 26 min surgery the patient received 50 µg of fentanyl intravenously in divided doses. Blood pressure, heart rate and oxygen saturation remained within normal limits and free movement of the legs (Bromage 0) was preserved during the procedure. The patient and her anesthesiologist maintained a conversation throughout. The surgeon rated operating conditions as satisfactory. The patient easily moved herself to the stretcher postoperatively and was highly satisfied with her anesthetic. No nausea or pruritus occurred. She was discharged uneventfully after a four-hour bedrest dictated by the obstetric protocol. This case shows that low-dose epidural anesthesia can be an alternative to SA for selected patients presenting for McDonald cerclage. Advantages include the absence of the risk for TNS, and possibly a reduced incidence of perioperative nausea and pruritus. The technique could be improved by using less volume of local anesthetic solution to achieve the T8 level of sensory blockade that suffices for this surgery. Placement of an epidural catheter perceived as cumbersome for outpatients may not be needed when employing a single-shot epidural technique instead. Comparative outcome studies are desirable.
References
1 Richardson M, Wissler R, Porth J. Cervical cerclage: spinal lidocaine vs bupivacaine/fentanyl. Anesthesiology 1998; 88 (SOAP Suppl.): A 32 (abstract).
2 Zahn J, Abramovitz SE. Subarachnoid fentanyl with low dose bupivacaine vs. lidocaine for cervical cerclage. Anesthesiology 1999; 90 (SOAP Suppl.): A 24 (abstract).
3 Ben-David B, Solomon E, Levin H, Admoni H, Goldik Z. Intrathecal fentanyl with small-dose dilute bupivacaine: better anesthesia without prolonging recovery. Anesth Analg 1997; 85: 560–5.[Abstract]
4 Freedman JM, Li DK, Drasner K, Jaskela MC, Larsen B, Wi S. Transient neurologic symptoms after spinal anesthesia: an epidemiologic study of 1,863 patients. Anesthesiology 1998; 89: 633–41.[Medline]
5 Pollock JE, Neal JM, Stephenson CA, Wiley CE. Prospective study of the incidence of transient radicular irritation in patients undergoing spinal anesthesia. Anesthesiology 1996; 84: 1361–7.[Medline]
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