Double epidural catheter technique in a patient with severe COPD undergoing major abdominal surgery: A case report

INTRODUCTION AND IMPORTANCE: Chronic Obstructive Pulmonary Disease (COPD) leads to the development of postoperative pulmonary complications (PPC), such as atelectasis, pneumonia and respiratory failure. The use of epidural anesthesia, alone or combined with general anesthesia, is known to reduce the incidence of PPC and shorten tracheal intubation time. In major procedures involving both the lower and upper abdomen, central neuraxial block at a single level may be inadequate to provide sufficient metameric extension of anesthesia. This limitation could be overcome with the use of double epidural catheter (DEC), has proved effective in diverse surgical scenarios. CASE PRESENTATION AND CLINICAL DISCUSSION: We present the case of a woman affected by moderate-severe COPD scheduled for major abdominal cytoreductive surgery due to ovarian malignancy with planned xypho-pubic laparotomy. We developed and implemented a DEC-based strategy for perioperative pain management based on the extent of surgical incision and the high risk of difficult weaning from ventilation and PPC. We used intraoperative monitoring to guarantee adequate antinociception throughout the entire 350 min long demolitive surgical procedure. No additional top-ups of intravenous analgesia or neuromuscular blocking agent (NMBA) was needed during surgery; at the end of the procedure, the patient was extubated in the operating theatre, maintaining adequate respiratory function during the whole postoperative period. CONCLUSIONS: The DEC technique could be beneficial for patients undergoing cytoreductive surgery. In our case, this technique granted optimal analgesic coverage and was instrumental in achieving fast weaning from mechanical ventilation and early tracheal extubation. Systematic studies on this subject are warranted.