|Year : 2014 | Volume
| Issue : 2 | Page : 256-258
Ischemic pain mandating unconventional position for epidural placement
Srivishnu Vardhan Yallapragada, Nagendra Nath Vemuri, Shaik Mastan Saheb
Department of Anaesthesia, NRI Medical College, Chinnakakani, Guntur, Andhra Pradesh, India
|Date of Web Publication||16-Jun-2014|
Dr. Srivishnu Vardhan Yallapragada
Department of Anaesthesia, NRI Medical College, Chinnakakani, Guntur - 522 503, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Positioning has always been a special and important concern for any regional anesthetic technique. The standard positions recommended for epidural anesthesia include lateral decubitus, sitting and prone. We report a special situation where we employed the standing position for placing epidural catheter. A 40-year-old man presented with severe ischemic pain of right lower limb due to near total thrombosis of right common iliac artery. He was scheduled for peripheral angiogram and referred to us for pain management as his pain was not permitting him to sit or lie down. Epidural analgesia was planned for managing the pain in the catheterization laboratory and for any other possible management intervention later. As the patient was not tolerating any position other than standing because of severe pain, we placed the lumbar epidural catheter in the standing position and quickly activated the analgesia in the supine position. Patient had good pain relief immediately and an infusion was commenced. Safety and comfort are the major issues to be addressed, while positioning for any procedure. Standing position was chosen for this particular case as it was the only comfortable position for the patient and the safety was not compromised.
Keywords: Pain, positioning, standing epidural
|How to cite this article:|
Yallapragada SV, Vemuri NN, Saheb SM. Ischemic pain mandating unconventional position for epidural placement. Anesth Essays Res 2014;8:256-8
| Introduction|| |
Positioning plays a pivotal role in the performance of any anesthetic procedure, be it general or a regional anesthetic. Inadequate positioning of the patient can negate an otherwise meticulous technique and should be prevented.  For every technique, an optimal position is recommended. The aspects usually taken into consideration, while deciding upon the ideal position for a given procedure are adequate exposure of the site of the procedure, safety of the patient and most importantly the comfort of both patient and the anesthesiologist. The standard positioning protocols thus designed are religiously followed for ensuring uniformity in the patient care and outcome. However occasionally in clinical practice, we do encounter special situations that may warrant some deviation from the set protocols. We seek to report one such special case where we had to perform epidural anesthesia in the standing position.
| Case Report|| |
The case we present here is about a 40-year-old man who was referred to our pain clinic with severe ischemic pain of right lower limb. The pain started gradually 10 months back and became very severe for the last 1 month. The intensity of pain was increasing in both the sitting and lying down positions and decreasing in a standing position. Many non-steroidal anti-inflammatory drugs were tried earlier without much benefit. Over the last 1 month, the severity of the pain was so bad that the patient had to stand all the time and sitting or decubitus position was not tolerable even for 1 min. His sleep was so miserable that he had been taking small naps in that standing position leaning onto some support. He had carcinoma rectum for which he underwent abdominoperineal resection 8 years ago. There was history of smoking prior to that. After the surgery, he had been leading a near normal life driving auto rickshaw for a living until he developed the present problem. There were many gangrenous ulcers over his right thigh and leg. A computed tomography-angiogram was done previously that showed a thrombus in the right common iliac artery measuring about 9.5 cm extending up to the right superficial femoral artery with a near total occlusion of the lumen and poorly developed collaterals. He was scheduled for a conventional peripheral angiogram for deciding on the further plan. However, he could not lie down in the catheterization laboratory due to severe pain and was referred to our Department of Pain Management. We initially tried a conservative approach with a combination of oral pregabalin, diclofenac, paracetamol, and tramadol as per the standard dosage protocol for 2 days. When there was no satisfactory pain relief, we planned epidural analgesia. However, the problem here was the positioning. Patient was not able to tolerate either sitting or lateral decubitus position even for 1 min. He was somewhat comfortable only in the standing position. Considering the special situation, though not conventional, we decided to place the epidural catheter in that standing position. An intravenous line was started using an 18G venous cannula. Electrocardiogram, pulse oximeter, and non-invasive blood pressure monitors were connected. Patient was made to stand besides the operating table holding on to it for support. He was also supported by a technician from the front [Figure 1]. After painting and draping the back, L 4-5 inter-space was identified and local anesthesia was given with 2% lidocaine. Epidural space was engaged with 18G Tuohy needle using loss of resistance to air technique. The epidural catheter was carefully threaded and placed such that the length of the catheter was 5 cm in the epidural space. Catheter was gently aspirated to check for blood and cerebro-spinal fluid and was fixed after subcutaneous tunneling for about 5 cm [Figure 2]. Patient was reassured and gently placed on the operating table in the supine position. A quick test dose was given with 3 ml of 2% lidocaine with 15 mcg adrenaline confirming the epidural placement followed by a bolus of 10 ml of 1% lidocaine along with 1 ml of 7.5% sodium bicarbonate. The pain was relieved within 1 min and the vital signs were stable. Epidural infusion was maintained thereafter with a solution of 0.125% bupivacaine and dexmedetomidine 2 mcg/ml at the rate of 5 ml/h. Patient was very comfortable and slept peacefully. Next day peripheral angiogram was performed, which confirmed the findings of CT-angiogram. Balloon angioplasty was attempted after 2 days, but was not successful and an above knee amputation was performed subsequently. Epidural catheter was removed after 2 days and further pain control was achieved satisfactorily with oral medications.
| Discussion|| |
The technique of epidural anesthesia has certain special considerations when practiced as an intervention for pain management than as a procedure of regional anesthesia for surgeries. Pre-existing physical and psychological condition of the patient, feasibility of positioning on the operating table and subsequent long term care of the epidural catheter are the essential issues to be addressed, while contemplating such an intervention. Long standing ischemic pain is not just a mere sensation of pain in the lower limb as it appears. The dynamics of chronic pain are predominantly influenced by four factors namely physical, social, psychological and spiritual.  Evolving episodes of throbbing pain progressively increasing in duration and severity do not allow the patient to sit or lie down. This leads to deprivation of sleep for days together, further adding to the suffering. This is only the physical side of the problem which is evident. Our patient belongs to a low socio-economic group and is the bread winner of his family. Prolonged periods of disability and joblessness, uncertainty about the treatment outcome, and a continuous worry about the family economy constitute the social, emotional and psychological contributors enhancing the impact of the pain exponentially.
The standard positions recommended for an epidural anesthetic are sitting and lateral decubitus positions with an optimal flexion of the back.  It was suggested that these positions open up the inter-vertebral spaces wide enough to conveniently access the epidural compartment. Prone position is preferred for caudal anesthetic technique in adults.  Prone position is also employed for accessing epidural space for steroid administration under fluoroscopy guidance.  To the best of our knowledge, epidural anesthetic technique performed in a standing position has not been reported so far. Patient was somewhat comfortable in a standing position because the lower limb perfusion was improved due to gravity. However, he was made to lean forward on to the operating table so that the lumbar interspinous spaces would optimally open up for engaging the epidural space. Standing is the poorest choice of position for any anesthetic procedure as it jeopardizes the comfort and safety of patient. However, in this case the same comfort became the indication for adopting the position. The element of safety was not bypassed as the standing position was employed only for placing the epidural catheter. No local anesthetic was administered through the catheter in that position. Nevertheless, still there was a possibility that the patient could develop vaso-vagal attack while performing the procedure. We took all the necessary precautions to deal with any exigencies. We had an established venous access and all the emergency drugs drawn up and airway equipment ready. Patient comfortably leaned onto the operating table and he was supported by a technician from the front. Two more senior anesthesiologists were available in the operating room fully ready to rise to the requirement in case of any complication. However, activation of anesthesia was done only in the supine position under strict hemodynamic surveillance. Alternatively, sitting or lateral decubitus position could have been facilitated by administering titrated doses of intravenous morphine or fentanyl. But the strong opioids are known to depress the respiration in the absence of a painful stimulus.  Thus, the risk of respiratory depression following the activation of epidural anesthesia outweighed the benefit offered in positioning. Our patient did not complain of any added discomfort owing to the procedure. Probably the single most hope of getting relieved from the miserable pain, which he had been experiencing over weeks would have made him comply with the procedure and the position. On the contrary, it may also be possible that the feasibility of placing epidural catheter in the "standing position" can match that in the conventional positions. Nevertheless, it would be premature to comment on this without valid evidence.
| Conclusion|| |
"Positioning" holds a key position in the success of an anesthetic procedure. Safety and convenience are the major issues to be satisfied during positioning. Standing position was employed for placing epidural catheter in one particular case does not give the message that we can afford to allow patients to stand up in the operating rooms on a routine basis. At the same time it is also not appropriate to preclude the use of such positioning just because it is not conventional. Concrete evidence is required in the current day clinical practice to advocate "hiring or firing" of anesthetic procedures and their protocols. Prospective clinical trials may be designed to analyze the merits and demerits of standing position for epidural catheter placement in such special situations. However, the implications of ethical considerations do have a significant say in this regard.
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[Figure 1], [Figure 2]