Whipple’s Operation Under Lumber Epidural Analgesia and Sedation

Abstract

Whipple's operation can be carried out either under general anaesthesia or continuous epidural anaesthesia with sedation. We report three cases that were managed successfully and we found that the combination of lumbar epidural analgesia with sedation is safer and beneficial as compared to those who undergo Whipple's operation under general anaesthesia. For the last three decades epidural analgesia has been the part of anaesthesia practice. Epidural analgesia can be a useful method of pain management various situations. It facilitates early mobilization and also avoids perioperative pulmonary complications especially after major thoracic or upper abdominal surgeries. The combination of continuous epidural analgesia with sedation has many advantages in prolonged major upper abdominal surgeries. Keywords- Whipple's operation, general anaesthesia, continuous epidural anaesthesia, sedation, upper abdominal surgery. I. Case Report We present 3 cases where regional anaesthesia technique combined with sedation for whipple's operation was employed successfully. Three patients with obstructive jaundice secondary to periampullary carcinoma posted for whipple's surgery. The diagnosis was confirmed by blood biochemistry, CT scan, ERCP and biopsy. General physical and systemic examination and vital parameters was essentially the same in all the patients. On pre-anaesthetic examination, an informed consent was taken and patients were thoroughly explained about the procedure and technique of lumbar epidural anaesthesia. After taking the patients in operation theater, patient were monitored for HR, BP, ECG, SpO2 and temperature. Intra Venous access was secured with 18 G cannula on the dorsum of hand and preloading was done with ringer's lactate solution 10-15ml kg-1. under full aseptic precaution an epidural catheter was inserted in the epidural space at L1-L2 level. The tip of catheter was advanced to T4. A test dose of 3 ml of 2% xylocaine with adrenaline 5 µg ml-1 was given after insuring correct placement the bolus dose of local anaesthetics (10ml of 2% lignocaine and 10ml of 0.5% bupivacaine and 50 micro g of fentanyl) was given followed by bolus dose of 6ml 0.5% bupivacaine hourly. Central venous cannulation was done and CVP maintained between 8-10 cm of normal saline. Opioids were not used. Urine output monitoring was done and maintained between 1.5-2 ml kg-1 hr-1. Blood loss was adequately replaced by PRBCs, FFP's and other IV fluids. Average blood loss in all 3 cases was 2-3 liters. The duration of surgery was approximately 8 hours. Propofol infusion 10ml hr-1 was used in all cases for sedation along with midazolam @ 2 ml/hour. Vital signs were monitered and maintained through out intraoperative period. All patients were fully conscious, oriented and with stable vitals. Postoperative x-ray Chest was normal in all cases. Postoperative pain relief was given with lumber epidural infusion. Bowel sounds were audible on 3rd postoperative day. Biochemistry, haematological and Blood Gas parameters was within normal limits. Patients remained comfortable, without pain and were discharged on 3-4th postoperative day from the ICU. epidural catheter was removed before discharge. All the 3 patients were ambulatory and with no complaint of pain.