Sedative Anaesthesia for X-Stop Procedure
by Dr B. Sharma Ghoorun (MD, FRCA)
Consultant in Anaesthesia and Intensive care unit at HRI
Posted on 31/12/07
X-stop procedure has become a popular procedure in the management of lumbar spinal stenosis. Below is a brief resume of my own experience in the anaesthetic management of this procedure. The patient is kept on the side which means the experienced anaesthetist can always provide extra anaesthetic agents and convert a sedative technique into a general anaesthetic one. This is one of the many safe features of this procedure. Every patient gets a good functioning intravenous cannula for drug administration, including intravenous fluid infusions and for emergency injection of rescue drugs. Each one is monitored just like any routine anaesthetic procedure. The surgeon infiltrates the incision site with local anaesthetics and proceeds to surgical incision only when the desired anaesthetic effects are achieved.
In my own practice, I have used 2mcgkg/ml (Total intravenous anaesthetic technique) of plasma level of Propofol for induction and then I have had to build it up to 3-4mcg/ml of plasma level, depending on:-
surgical stimulation
respiratory and haemodynamic parameters
patient's response or demand
I have stopped using Remifentanyl as an adjunct as I have experienced more respiratory depression with the latter technique. I have provided X-TOP sedation for about 7-9 patients, and out of them all, one needed very deep level of anaesthetics which had to be converted into general anaesthetics. However, in this patient, I used a combination of Sevoflurane and oxygen for induction and I maintained anaesthesia with a combination of oxygen, air, Sevoflurane, and a laryngeal mask airway. Spontaneous respiration was maintained throughout. This patient had the habit of consuming above average amount of alcohol related beverages and I did anticipate minor problems with sedation. However, I should highlight that the cases we have done with Mr Tolessa, were discharged safely and without delay, both from the recovery area, as well as from the ward, which have contributed hugely to staffs' and patients' satisfaction. As an anaesthetist, I see X-TOP as a spinal procedure with well documented chronic pain relieving effect on the back, attempted on the same day and with minimal disruption of patients' life styles. From the patient's point of view, this is equally very safe because the surgeon hardly interferes with his/her cord or the nerve roots of the cord.
Postoperatively, most patients are very comfortable as the local anaesthetic is still active for a while. However, at least 2 patients in my practice have requested analgesia in the recovery. Hence, these days I routinely administer a COX2 blocker (Parecoxib 40 mgs IV) and intravenous Tramadol 50 -100mg intra-operatively, provided there is no obvious contra-indication to these drugs. Almost all of them get regular Paracetamol tablets, and with exceptions of those who have serious contra-indications, all receive either ibuprofen 400mgs tablets at 8 hourly intervals or Celebrex 100mgs capsules at 6 hourly intervals, for at least 2 days. On a 'as required basis' they also get a supply of Tramadol 100mg tablets at 6 hourly intervals and an anti-emetic of choice.
With experience and with an increasing through-put of day care procedures, provision of sedation anaesthetic in combination with local anaesthetics is becoming a highly demanded skill. Every anaesthetist has a set of established techniques or habits. However, it is imperative that patients'consent and safety be considered at all times.
Pearls
Practitioner must ensure that the patient understands that push and pull sensations can be uncomfortable and these feelings can not be completely eliminated.
Have adjunct airways, including a nasopharyngeal airway handy.
Be prepared to protect the airway and control the ventilation if things do go wrong.
Any procedure can be converted into a general anaesthetic, so be always on the guard.
In anaesthetic practice prior anticipation and a pro-active approach avert problems
Communicate, communicate, and communicate!
The content of this article is based on my personal experience. I do not bear any responsibility if any one, without adequate prior practical experience and without direct training, experiments with it and lands up in medico-legal consequences.
Bibliography
Symington,L., Thakore, S., ( 2006). A review of the use of propofol for procedural sedation in the emergency department. Emergency Medicine Journal 2006; 23:89-93.
