liver abscess rupture done under thoracic epidural anaesthesia

[frontier]

i, dr.simant kumar jha,writing from ranchi,india.i am an anaesthesiologist by profession .on 19.12.2006 a laprotomy done for ruptured liver abscess with rt pleural effusion done under thoracic epidural given by me.space chosen wa t8-t9.catheter was placed.as oxygen saturation was only 85% preoperatively & patient was breathless with rt lung involved,crepitations found on auscultation.i gave initially 10 cc of 2%lignocainewith adrenaline.later on 5 cco this one again was given as top up.atoat of 10 cc of .5%bupivacaine given through epidural catheter.100 mg of tramadol also given through catheter.50 cc of iv ketamine given initially.again 50 mg of iv ketamine iv given.8 mg of dexamethasone iv given intraoperatively.atotal of 1800 ml of iv fluid given through rt internal jugular vein which also included 300 cc of fresh blood.only once BP CAME DOWN to 90/60mm of hg.a total of 12 mg iv ephedrine used.urine output 440 cc post op.BP was 11o/70 mm of hg postoperatively.next day patient fine ,responding.intraoperatively oxygen given through mask at frequent intervals

[swatantramishra]

well i dont know the fun of getting a case of RUPTURED LIVER ABCESS WITH RIGHT SIDED PLURAL EFFUSION SIGNIFICANT ENOUGH TO COMPROMISE SPO2 to be done under epidural anaesthesia.this is an obviouss emergency in which ensuring the safety of the patients is of paramount importance,this man was definitely sick and required adequate respect for his condition,what was contraindication of not getting the case done under G.A.,in other words what advantage d o we gain operating such case under TEA. although TEA might be a good idea to take care of the postoperative pain.what was the coagulation profile like

[frontier]

hi,
  the condition of the patient was really serious,so i opted to go for thoracic epidural/one reason was patient rt lung was involved as i found crepitations on auscultation which was hampering patient' breathing leading to decreased SPO2.so i didn't want to take the chance as i thought this may create problem while reversal & i may have to put the patient on ventilator .with my previous bad experiences in such cases while weaning i thought to give thoracic epidural/patient BT,CT,PT,PLATELET COUNT WERE ALL NORMAL/YES POST OP ANALGESIA WAS AN ADDED ADVANTAGE/

[swatantramishra]

hello doctor,
                  I can not still understand the logic of getting the case done under TEA when you yourself found that patient was pretty sick,I am sure you are aware of the recommandation for getting caes done under TEA.Already the patient was desaturating what if you have higher than required block?you would have landed nowhere,are there any description of getting the case done like this?would you have done this to a patient in west?or even any of the private corporate set up in India?

[frontier]

hi,
its risky to do the things under thoracic epidural block,but you have to be extra vigilant so that your block is not higher,always titrate the dose through catheter.even such cases under GA also risky.what i did i was providing oxygen to the patient through mask & i was ready to meet any catastrophe.i could have intubated the patient,but everything remained alright.see whatever mode of anaesthesia you choose has got its own advantages & disadvantages.i thought that time giving thoracic block will be beneficial for the patient & patient is fine now.