scleroderma, a chronic, systemic disease that effects the lungs, skin, heart, gastrointestinal tract, kidney and musculoskeletal system. The article is a case report on a specific case dealing with achalasia due to scleroderma and multiple left lung hydatid cysts which the practicioners performed a thoracic epidural blockade in combination with general anesthesia with air-oxygen and sevoflurane without neuromuscular blockade and without intravenous opioids.
The surgical procedure involved using an epidural catheter prior to inducting anesthesia. After the surgery, the anesthesia was discontinued and twenty minutes later that patient began spontaneous breathing, responding to painful stimuli and to buck on the tube.
In general, it is found that scleroderma is a connective tissue disease and an autoimmune disorder which causes vascular damage, especially in capillaries and small arterias. Further, achalasia and scleroderma account for the vast majority of surgical procedures performed for motility disorders.
It is essential that the anesthesiologist understand the pathophysiological processes of the diseases in order to minimize potential risks involved during the administration of anesthesia. These risks include aspiration and other pulmonary complications. Other risks, although more remote, include a potential for reduced renal function and intraoperative hypothermia-induced vasospasm.
According to the study, regardless of the actual surgical procedure, “the major anesthetic consideration for patients with esophageal disease is the risk of pulmonary aspiration.” The study states that to reduce these risks, certain steps must be taken both before and during the administration of the anesthesia. For example, consideration should be given to administering metoclopramide, H2 blocker or a parietal cell proton-pump inhibitor prior to the operation. More so, the patient should always be transported to the operation room in a semi-upright position and with the assistance of supplemental oxygen. Finally, the case study found that “anxiety was prevented providing sedation with midazolam before anesthesia induction.”
This study also provides numerous important, helpful and practical advice to the practicing anaeshesist. For example, in these procedures it is often difficult to open the patient’s mouth wide enough for laryngoscopy and intubation, thus creating the possibility that cardiopulmonary changes may be present and the “probability o lesions in oesophagus, bowel, kindneys, skin and joints.” This information would not be known if not for this study and its reported findings.
The study’s conclusion is that the use of thoracic epidural anesthesia to sevoflurane based inhalation “may be a suitable technique for thoracic surgery in achalasia due to sclerodermic patients.” The reason for this conclusion is that the study found that this procedure “can provide a smooth anesthesia course and a rapid recovery, with hemodynamic stability, and also having pain-free postoperatively.” More so, the study found that providing anesthesia without neuromuscular blockade and non-intravenous opioids has “provided a shorter recovery time.”
Clearly this specific case study has important and practical implications to the practice of anesthesiology. Besides from the benefits it provides for inducing anesthesia in this type of surgical procedure, this case study also provides an excellent example for proper analysis and methodology of a study. The report began with posing the question as to the best course of administering anesthesia in a surgical procedure involving thoracic epidural blockade in a patient with achalasia due to scleroderma. To reach its conclusion, it followed and measured the procedure and its effects as performed on an eighty-four-year-old male. These results were then compared to results gathered from previous procedures where other methods were used, allowing the researches to draw the conclusions that they did in the case study at hand.
Erol, Demet Dogan, M.D. (2006): “Thoracic Epidural Blockade in an Elderly with Achalasia Due to Scleroderma for Thoractomy, Esophageal Myotomy and Cystotomy-Capitonnage. The Internet Journal of Anesthesiology. Vol. 11, Number 1.
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