title: Neuraxial anesthesia and intraoperative bilevel positive airway pressure in a patient with severe chronic obstructive pulmonary disease and obstructive sleep apnea undergoing elective sigmoid resection.
abstract: OBJECTIVE
  This case report describes the anesthetic management of a patient with severe chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) who underwent elective sigmoid resection under combined spinal-epidural anesthesia and bilevel positive airway pressure (BiPAP).
  
  
  METHODS
  A 63-year-old man with diverticular disease presented for a sigmoid resection. His medical history included coronary artery bypass grafting, diabetes mellitus, gastroesophageal reflux, chronic renal failure, COPD, a paralyzed left hemidiaphragm, and OSA treated with nighttime BiPAP and oxygen. Sigmoid resection was performed under combined lumbar spinal-thoracic epidural anesthesia without general anesthesia and/or endotracheal intubation (intrathecal 3.5 mL isobaric bupivacaine 0.5% with 100 microg epinephrine and 200 microg morphine [Epimorph], epidural 60 mg bupivacaine, and 200 mg lidocaine). Intravenous ketamine was administered at a rate between 30 and 50 mg/h. Intraoperative BiPAP was applied using a setting of 12.5/8mm Hg with a backup ventilation rate of 10 breaths/min and an oxygen flow of 4 L/min. After surgery, epidural bupivacaine (0.1%) was infused over 3 days at 10 ml/hr supplemented with oral acetaminophen, resulting in excellent pain relief. Postoperatively, the patient continued to use BiPAP when sleeping, and no adverse respiratory events were observed. The patient was discharged home 5 days after surgery.
  
  
  CONCLUSIONS
  Combined spinal-epidural anesthesia was successfully used in a patient with COPD and OSA undergoing sigmoid resection. Perioperative administration of BiPAP, excellent pain control by continuous epidural infusion of local anesthetic, and the avoidance of endotracheal intubation may have contributed to this patient's uncomplicated postoperative course.
authors.affiliation: Department of Anaesthesia and daggerSurgery, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
authors.forename: Miroslava
authors.initials: M
authors.lastname: Kapala
authors.forename: Sarkis
authors.initials: S
authors.lastname: Meterissian
authors.forename: Thomas
authors.initials: T
authors.lastname: Schricker
mesh_terms: D015360:Analgesia, Epidural / Q000379:methods; D000767:Anesthesia, Epidural; D000775:Anesthesia, Spinal; D000779:Anesthetics, Local / Q000008:administration & dosage; D001062:Appendectomy; D002045:Bupivacaine / Q000008:administration & dosage; D003082:Colectomy; D045422:Continuous Positive Airway Pressure; D017558:Elective Surgical Procedures; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage; D007262:Infusions, Intravenous; D007430:Intraoperative Care; D007649:Ketamine / Q000008:administration & dosage; D008159:Lumbar Vertebrae; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000517:prevention & control; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications*; D012720:Severity of Illness Index; D012810:Sigmoid Diseases / Q000150:complications / Q000601:surgery*; D020181:Sleep Apnea, Obstructive / Q000150:complications* / Q000628:therapy; D013904:Thoracic Vertebrae; D016896:Treatment Outcome
chemical_list: D000779:Anesthetics, Local; D006993:Hypnotics and Sedatives; D007649:Ketamine; D002045:Bupivacaine