|Year : 2020 | Volume
| Issue : 4 | Page : 200-202
Anesthesia management of a patient undergoing exploration-decompression spinal canal and lumbar fusion procedure with diaphragmatic hernia
Tjokorda Gde Agung Senapathi, Andi Irawan, Adinda Putra Pradhana
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Bali, Indonesia
|Date of Submission||15-Jun-2020|
|Date of Decision||16-Jul-2020|
|Date of Acceptance||29-Jul-2020|
|Date of Web Publication||3-Nov-2020|
Dr. Tjokorda Gde Agung Senapathi
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. PB Sudirman, Denpasar 80232, Bali
Source of Support: None, Conflict of Interest: None
A diaphragmatic hernia is an abnormality of abdominal organs entering the thoracic cavity due to a defect in the diaphragm. Diaphragmatic hernias are divided into congenital or acquired that can develop from blunt or sharp trauma. In hernias due to blunt trauma, the common symptoms reported are limited to gastric disorders. The patient can come to the health facility for other reasons and, in this case, is a radicular pain due to spondylolisthesis. In this case report, a 67-year-old woman suffered from spondylolisthesis, which would carry out a decompression-stabilization and fusion procedure in a prone position, and at the time of preoperative examination was found to have a diaphragmatic hernia comorbid. Anesthetic management in cases of comorbid diaphragmatic hernias must emphasize the possibility of a full gastric condition. With careful anesthesia management, the challenges to overcome the condition in this patient can be done properly.
Keywords: Diaphragmatic hernia, general anesthesia, prone position, spondylolisthesis
|How to cite this article:|
Agung Senapathi TG, Irawan A, Pradhana AP. Anesthesia management of a patient undergoing exploration-decompression spinal canal and lumbar fusion procedure with diaphragmatic hernia. Bali J Anaesthesiol 2020;4:200-2
|How to cite this URL:|
Agung Senapathi TG, Irawan A, Pradhana AP. Anesthesia management of a patient undergoing exploration-decompression spinal canal and lumbar fusion procedure with diaphragmatic hernia. Bali J Anaesthesiol [serial online] 2020 [cited 2020 Nov 30];4:200-2. Available from: https://www.bjoaonline.com/text.asp?2020/4/4/200/299803
| Introduction|| |
A diaphragmatic hernia is an abnormality of abdominal organs entering the thoracic cavity due to a defect in the diaphragm. Diaphragmatic hernias are divided into congenital or acquired, which can occur due to blunt or sharp trauma resulting in diaphragmatic tears. Diaphragmatic hernias may not always cause clinical symptoms or frequently are only mild and often forgotten and undiagnosed., Up to 53% of patients are asymptomatic in hernias due to blunt trauma, while the most common symptoms reported are limited to gastric disorders and often being mismanaged.
Anesthetic management in cases with a comorbid diaphragmatic hernia must emphasize the possibility of a full stomach condition. In general, this management involves giving large intravenous access, invasive blood pressure monitoring, smooth intubation, prevention of increased intra-abdominal pressure (during induction, intubation, and extubation), and providing low tidal volume ventilation., Management of the diaphragmatic hernia itself is not imminent, and if without any emergency occurrence, the procedure to overcome this condition can be done at a later time. Sometimes, the patient needs other more urgent treatment that depends on the patient, which in this case is a radicular pain due to spondylolisthesis.
Spondylolisthesis is a shifting segment of the vertebrae against other vertebrae and often causes pain due to the involvement of the radicular nerve. The treatment of high-degree spondylolisthesis is by surgery, which is a combination procedure of decompression and fusion with or without any fusion aid. Surgical treatment for spondylolisthesis requires a prone position for the patient. Physiological changes in the body with anesthesia in the prone position can occur in almost all organs and, most importantly, the function of the heart and respiration. Due to its comprehensive effect, the incidence of complications can also occur in various organs, including those of the eye, mouth, peripheral nerves, and the skin. The management of anesthesia in a patient with comorbid of hernia diaphragmatic is quite complex, while the position of prone has its challenges in the anesthesia approach.
| Case Report|| |
A 67-year-old, 52 kg, 158 cm woman came with complaints of low back pain for 2 years. The pain was radiating from the back to both legs and getting worse after mild physical activity. The pain was also worsening when the patient is lying but improving in sitting position. She also complained of tingling on both legs, especially the left leg, but there was no complaint regarding the muscle strength. The symptoms began after the patient suffered from a motorcycle accident 2 years earlier. The patient also has a history of recurrent gastric disorders and uncontrolled high blood pressure since a year ago.
The numerical rating score was 4 out of 10. The breath frequency was 14 times/min, vesicular sound on both lungs, oxygen saturation 98%, Sabrazes test lasted for 25 s, blood pressure of 160/90 mmHg, and 92 beats/min heart rate. No bowel sounds were heard in the thoracic cavity. Blood tests were within normal limits. A chest X-ray [Figure 1] showed a picture of a suspected necrotic lung mass with a differential diagnosis of a suspected hiatal hernia. Thorax computed tomography (CT) scan [Figure 2] revealed a tubular structure with a picture of valvulae conniventes and multiple hypodense air lesions projected in the inferomedial aspect of the mediastinum, which passes through the esophageal hiatus, indicating a hiatal diaphragmatic hernia.
|Figure 1: Thorax posteroanterior of the patient showing a picture of a suspected necrotic lung mass with a differential diagnosis of a suspected hiatal hernia (inside the red circle)|
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|Figure 2: Thorax computed tomography scan of the patient showing a hiatal hernia (shown in the red box; a, coronal plane; b, sagittal plane)|
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She was given premedication with ranitidine 50 mg, dexamethasone 10 mg, and midazolam 2 mg. In the operating room, standard American Society of Anesthesiologists monitoring was applied. After 5 min of preoxygenation, she was induced with propofol 200 mg and 100 mcg of fentanyl, using rocuronium 50 mg to facilitate endotracheal intubation.
We then carefully positioned the patient in a prone position. The donut-shaped pads were wrapped around the edges of the face, while the eyes, nose, and lips were ensured pressure free. Pads on the face were also arranged so that the neck position was in a neutral position. The arms were positioned abducted, and pads were placed under the elbows. The chest wall was held with two pillows on both sides while the abdomen left free. The pelvis was padded on the anterior superior iliac spine region.
For maintenance, we used compressed air and oxygen mixture to acquire a 60% inspired oxygen fraction, with a pressure control ventilator adjusted to get a tidal volume of 6 mL/kg and a breathing frequency 18 times/min. For hypnotics, the patient was given continuous propofol, while analgesic fentanyl and muscle relaxant rocuronium were administered intermittently to suit the patient's needs. The patient was also given ondansetron and tranexamic acid. The hemodynamics during surgery tended to be stable without much bleeding.
At the end of the surgery, an epidural catheter was placed by the surgeon. The patient was then returned to the supine position, and smooth extubation was done facilitated by intravenous lidocaine administration. Postsurgery, the patient was sent to the ward with epidural analgesic bupivacaine 0.1% + morphine 1 mg in 10 mL NaCl 0.9% every 12 h with paracetamol 500 mg every 6 h orally. On the 4th day after the surgery, the patient was discharged with minimal pain.
| Discussion|| |
In this case report, a 67-year-old woman with lumbar canal stenosis in L2–L3, L3–L4, L4–L5, and spondylolisthesis L4–L5 will have a posterior decompression stabilization fusion procedure in a prone position. However, during the preoperative examination, it was found that the patient had diaphragmatic hernia abnormalities.
The diaphragmatic hernia has challenges in the management of anesthesia, especially for the risk of gastric content aspiration and also the risk of an increased volume of abdominal organs protruding to the thoracic cavity. For this reason, during preoperative, the patient was educated to have food fasting for 10 h, which aims to ensure gastric emptying, and also given ranitidine and dexamethasone premedication. At the time of preinduction in the operating room, the patient was given oxygenation with 100% oxygen for 5 min without positive pressure. This was to avoid the insufflation of the gaster. Induction was with propofol, analgesic fentanyl, and muscle relaxant rocuronium. Intubation in patients with diaphragmatic hernia is usually carried out by the rapid sequence intubation technique. Nevertheless, we did not use such a technique after it was confirmed that the patient's fasting was sufficient. It was evident that with careful anesthetic management the regurgitation and aspiration of the gastric fluid did not occur. The patient was then carried out an invasive blood pressure monitor to evaluate any hemodynamic changes during the procedure carefully.
The patient is then positioned prone with someone continuously holding the endotracheal tube (ETT) to avoid tube dislodgement during the positioning process. She was given padding on the thoracic region, with pillows on both sides of the chest and the pelvic. We ensured that no pressure occurred on the eyeball, and the ETT was freed from any compression. Finally, the lung was examined for symmetrical expansion during ventilation.
The paddings of the chest were ensured rest on both sides while the abdominal cavity left free. The arms were positioned in abduction, and we placed water-filled balloons as a padding on the elbow to prevent ulnar nerve pressure. When positioning a patient into prone, malposition can occur on any part of the body, and the risk of injuries greatly increases. The pressure that takes place on the abdomen can result in the worsening of the existing hernia and even precipitate an emergency. During the procedure, the patient was given a relatively lower tidal volume according to the patient's body weight with a higher breathing frequency to avoid increasing in intrathoracic pressure, which can result in increased abdominal pressure. By hindering any external pressure to the abdomen while maintaining intrathoracic pressure low, it is expected that the deterioration of the hernia can be avoided.
Anesthesia in this patient was maintained well during the procedure that lasted for 3 h. During the procedure, there were no significant hemodynamic changes nor emergencies related to the patient's condition. At the end of the procedure, the patient was awakened and carried out an awake extubation procedure. Extubation was done smoothly, and the patient did not experience any cough during extubation. The patient was then transferred to the ward and given postoperative analgesic epidural bupivacaine 0.1% with morphine 1 mg in 10 mL of NaCl 0.9% every 12 h combined with paracetamol 500 mg every 6 h orally. Postoperatively, an evaluation of the patient's vision was still in reasonable condition, and any peripheral nerve injury, primarily sensory and motoric of the ulnar nerve, was not found. The patient was discharged on the 4th day with no pain.
| Conclusion|| |
This case report presents the management of anesthesia in a patient with a comorbid diaphragmatic hernia who must undergo surgery in the prone position. With careful management of anesthesia, any risk involving both prone position and diaphragmatic hernia, such as postoperative visual loss, nerve injury, deterioration of the hernia, and emergency related to the hernia, did not occur. It is proven that these procedures can be done well, even without the rapid sequence intubation technique.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]