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Clinical cases
Dr Abdullah Alsailamy
A 75-year-old man w ith chronic obstructive airways d ise a se requires a transurethral resection of the prostate. Out line the advantages and disadvantages of suba ra ch no id anaesthesia for this patient.
This q uestion does no t require a genera l ge ne ric discu ssion of the ad vantages and disad vantages of sp inal anaesthesia. You shou ld focu s yo ur answer round the fact , 5 ch ronic obstructive pu lmonary d isease. Both the su rgica l cond ithat the patient h,1 tion an d the medical di sease arc com m o n.
Intro d u ct io n Transurethra l uro logy lends itself well to reg iona l anaesthesia, bu t despite this not all urolog ical su rgeons share the anaes thetlsts' enth usias m and if given a choice prefer general an aesthesia. Coexisting pu lmonary d isease makes the argu ments in favour of subarach noid or ex trad ural analgesia more pers ua siv e, although there rem ain some d isadvantages.
In the patient with CO PD: main advantages lie in avoida nce of ge neral anaesthesia Full control of the airway and b rea thing. No airway instrumen tati on w ith the atte ndan t risk of provoking b ronchoconstrict i on. No risk of barotrauma (pneumothorax) with IPPV. No respirato ry dep ression. No d ifficulty in resum ptio n of adequate spon taneous ventilation . Lower risk of postoperative chest infection . Advan tages s peci fic for TU RP Earlier and easier detection of the TUR P synd rome. Ge neric ad va ntages of th e technique Possible lower risk of venous e mbolism. Good postopera tive analgesia (although pain after TURP is not usually severe). In th e patien t with COP D th e disadvantage s of spinal ana esth esia include: Respiratory compromise if the b lock sp reads to involve the intercosta l muscles. Patien ts w ith COPD may find it d ifficult to lie flat. Persistent coughing wi ll interfere with surgery. C ":I'I1l'riC di sadva ntages of th e techniq ue: I lypotension (in an elderly age group). Unsuitable fo r the restless or uncooperati ve patient. Stuno suggestion that there is increased fibrinolysis under suba rachnoid b lock (SAIl). Rlsk of postd ural puncture headache (small).
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How w ould you assess a patient with chronic obstructive pul m o nary disease (CO PO) who presents for laparotomy? Wha t a re the major perioperative risks and how may they be reduced?
A patient w ith se ve re COPD can p rese n t significan t anaesthetic challenges, the m ain one being how to ens ure that they may be kept off a ventilato r and o ut of an intensive care u nit. COPD is a spectrum o f d isease and the questio n is assessing your know ledge of the cond ition and yo u r judgement in its management.
Introduction
The cardina l feature of chronic obs truct ive pulmona ry d isease is increased ai rways resista nce to fl ow (hence th e alternative title of chronic obs tructive airways di sease). COPD is cha racterised by a disease spectru m tha t ranges from chronic bronchitis w hich lim its activity only m ildl y, to severe and incapacitating em ph ysema.
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Risk reduction
The key to risk reduction is the op timisation of the patient's peri opera tivc cond ition : Smo king. Cessa tion is d ifficult in patien ts w ith a lifelong habit, bu t redu ction in postoperative respiratory morbidity w ill resul t it it can be achieved 2 months prio r to surgery. Pharmacology. Optimise the regim en, particul arly if there is a reversible com po nent. Approp riate antib iotic treatment o f any intercurren t chest infection. Physiotherapy. Pre-emptive and w ith use of techn iqu es such as incentive sp irometry. Analgesia. Good postoperative ana lgesia (i.e. by epid u ral) w ill red u ce respiratory com plica tions incid en t upon di aphragmatic splin ting and basal atalectasis due to inhibition of d eep brea thi ng by pain. Regional an aesth esia. Use wherever feasible, b ut must bew are anaesthetising the intercosta l muscles with high neu raxial blocks, or using techniques which impair ph renic nerve fu n ction (in terscalene block ). Am b u lation. Encourage early mobilisation.
Marking points: Clinical exper ience and judgement is as impo rta nt as the
respiratory numbers in deciding whet he r or not these pati ents are going to require postoperative intensive care. You need to emphasise those clinical features as well as outlining an a naest hetic st rategy that will minimise th at risk. Good preoperative pre paration and optimal postoperative a nalgesia are crucial to that aim.