P053: AWAKE OPEN HARTMANN'S PROCEDURE UNDER LUMBAR EPIDURAL ANESTHESIA IN A PATIENT WITH NEAR-CRITICAL SUBGLOTTIC STENOSIS AND SEVERE COPD/CAD
Ekaterina Broome, MD; Sofia Lifgren, MD
HCA Florida Kendall
Introduction/Background: Severe fixed upper-airway obstruction creates a high-risk anesthetic scenario because induction of general anesthesia may precipitate inability to ventilate and/or intubate, and extubation may also be hazardous. For selected abdominal operations, neuraxial anesthesia can avoid airway instrumentation and preserve spontaneous ventilation, but it requires a clear plan for supplementation or conversion if the block is inadequate. We report an open Hartmann’s procedure performed under epidural anesthesia in a patient with near-critical subglottic stenosis and significant cardiopulmonary comorbidity.
Methods: A 77-year-old male with laryngeal cancer treated with chemotherapy and radiation, severe emphysema on home oxygen, and coronary artery disease with prior PCI presented with an obstructing sigmoid colon tumor requiring Hartmann’s procedure. Preoperative evaluation demonstrated partial vocal cord paralysis, and CT imaging showed approximately 95% subglottic stenosis. Given the high risk of airway instrumentation, shared decision-making among anesthesiology, surgery, and the patient led to primary neuraxial anesthesia with difficult-airway preparedness (video laryngoscope and flexible bronchoscope available; surgical airway contingency discussed). An epidural catheter was placed at L3-L4. Local anesthetic (0.5% bupivacaine) was incrementally titrated to achieve anesthesia. Sedation/analgesia was provided with small doses of intravenous midazolam, ketamine, and dexmedetomidine to maintain comfort while preserving spontaneous ventilation.
Results: The patient remained awake, spontaneously breathing, and stable throughout. Epidural anesthesia provided adequate conditions for completion of the open Hartmann’s procedure without conversion to general anesthesia or need for airway instrumentation. The patient experienced mild discomfort with traction and tissue manipulation, consistent with the limitation of neuraxial techniques for visceral traction pain despite an appropriate block level. No emergent airway intervention was required.
Discussion: Neuraxial anesthesia has been described as an alternative to general anesthesia for colorectal surgery in high-risk patients with severe pulmonary disease, including “awake” surgery performed under epidural-based techniques to avoid airway instrumentation and preserve spontaneous ventilation. A combined spinal-epidural (CSE) could also have been considered because it can provide rapid onset and dense anesthesia and has been reported for sigmoid resection/colectomy in patients with severe COPD, including approaches incorporating noninvasive ventilation. However, in this patient with severe emphysema and CAD, we favored an epidural-only technique via lumbar placement (L3-L4) because it permits gradual, titratable dosing to the desired level and may reduce the risk of abrupt sympathectomy and sudden hypotension- particularly relevant in CAD, where hypotension and reflex tachycardia can worsen myocardial oxygen supply-demand balance. Given near-critical subglottic stenosis, avoiding overshoot in block height and minimizing the need for deep sedation (and potential loss of ventilatory drive) were priorities to reduce the likelihood of forced conversion to airway instrumentation. Observational data in COPD populations suggest regional anesthesia may be associated with lower pulmonary morbidity (including pneumonia, prolonged ventilator dependence, and unplanned postoperative intubation) compared with general anesthesia, supporting neuraxial approaches when surgical conditions permit.
Conclusion: In a patient with 95% subglottic stenosis and severe COPD/CAD undergoing open Hartmann’s procedure, carefully titrated lumbar epidural anesthesia with light ketamine/dexmedetomidine-augmented sedation enabled completion of surgery while maintaining spontaneous ventilation and avoiding airway instrumentation, with difficult-airway preparedness throughout.