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Canadian Journal of Anesthesia 50:312-313 (2003)
© Canadian Anesthesiologists' Society, 2003

Correspondence

Epidural analgesia for a laparotomy in a morbidly obese patient with a history of difficult intubation

Karen Loo, MD, Steven Backman, MD PhD, Anne Moore, MD and Thomas Schricker, MD PhD

Montreal, Quebec

To the Editor:

We describe the case of a morbidly obese male (61 yr, body mass index 54 kg•m2), who presented with recurrent evisceration after gastric bypass surgery for emergency laparotomy. Examination yielded a dyspneic patient secondary to pneumonia. The airway was graded as Mallampati 2 with good neck extension. Co-morbidity included obstructive sleep apnea and mild asthma. The anesthesia chart prior to gastric bypass surgery recorded a difficult mask ventilation and a Cormack grade III view on laryngoscopy despite a Mallampati 1 airway. When presenting for the first wound dehiscence repair one week earlier the airway was classified as Mallampati 3 and an awake fibreoptic intubation was performed (S.B.). After this operation the patient remained intubated for eight days due to adult respiratory distress syndrome.

Taking into account the patient’s co-morbidity, the ongoing pneumonia, the previous difficult intubation and prolonged weaning and considering the potential benefits of neuraxial blockade we (T.S. and K.L.) felt compelled to conduct the laparotomy under regional anesthesia.1–3

A low thoracic epidural catheter was inserted. Sensory block to T3 was obtained by lidocaine (100 mg) and maintained during the three-hour-mesh-graft-insertion by bupivacaine (total 85 mg). While the patient did cough intermittently, boluses of midazolam (2 mg), ketamine (200 mg) and propofol (165 mg) provided acceptable surgical conditions. Oxygen was delivered by face mask resulting in a SaO2 at 99%. Blood gases before and during surgery are presented in the TableGo. Postoperatively, we administered epidural bupivacaine 0.1% and fentanyl 3 µg•mL-1 at 14 mL•hr-1. The patient was pain free at rest and recovered uneventfully.


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  		TABLE Arterial blood gas analyses before and during surgery
 
Eight days following discharge he again presented with wound dehiscence and evisceration. Given an elevated partial thromboplastin time (39.3 sec) and prothrombin time (INR 1.28) and the surgeon’s wish for complete muscle paralysis a rapid sequence induction was performed (A.M.) with propofol, remifentanil and succinylcholine. Laryngoscopy showed a Cormack grade I view and the trachea was intubated easily. The patient was extubated in the operating room and had an uneventful recovery.

This case is interesting with regards to four issues: 1) avoidance of endotracheal intubation in a morbidly obese individual undergoing upper abdominal surgery by providing adequate epidural analgesia; 2) the varying assessment of the same airway as Mallampati 1, 2 and 3, which can be explained by high interobserver variability and the patient’s varying medical condition during his hospital stay;4 3) the need to carefully assess previous anesthetic decisions and weigh them against one’s own clinical judgement; 4) the controversy of securing the airway before starting surgery vs attempting to circumvent a potential airway problem by using a regional anesthetic technique.

References

1 Postlethwait RW, Johnson WD. Complications following surgery for duodenal ulcer in obese patients. Arch Surg 1972; 105: 438–40.[Medline]

2 Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg 1998; 86: 598–612.[Abstract]

3 Rigg JR, Jamrozik K, Myles PS, et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359: 1276–82.[Medline]

4 Karkouti K, Rose DK, Ferris LE, Wigglesworth DF, Meisami-Fard Lee H. Inter-observer reliability of ten tests used for predicting difficult tracheal intubation. Can J Anaesth 1996; 43: 541–3.[Free Full Text]





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