Epidural or spinal anesthesia in endoscopic stricture ureteroscopy

The article was professionally consulted with Master, Doctor Le Hong Duong - Anesthesiologist - Department of General Surgery & Anesthesia - Vinmec Hai Phong International General Hospital.

Ureteral stenosis can be the result of surgical intervention in the ureter, tumors pressing on the ureter, or congenital diseases. Urethral stricture must be indicated for surgery, namely laparoscopic dilation of the ureteral stricture under epidural anesthesia or injection of anesthetic into the subarachnoid space.

Anesthesia to anesthetize for endoscopic stricture ureteroscopy is a regional anesthetic technique that is performed by injecting local anesthetic into the subarachnoid space (spinal anesthesia) or epidural space (epidural anaesthesia). to meet the requirements of anesthesia and analgesia, help endoscopic retrograde dilation of the narrowed ureter.
Epidural or spinal anesthesia is indicated for analgesia and analgesia in endoscopic retrograde ureteral stricture and is contraindicated in the following cases:
The patient refuses to perform the procedure. Anesthesia reaction Inflammation of the needle puncture site Lack of adequate volume of circulation, possibly shock Patient with coagulopathy Insufficient anticoagulation time stopped Patient has mitral stenosis constriction, aortic valve constriction Severe heart failure decompensation Person performing the technique of epidural or spinal anesthesia:
Anesthesiologist specialist nurse is appointed to perform.

Emergency resuscitation equipment: oxygen source, Ambu balloon, mask, intubation equipment, anesthesia machine with breathing apparatus, electric shock machine, suction machine... Medicines: ephedrine, phenylephrine, adrenaline, barbituric, benzodiazepine, drugs muscle relaxant, intralipid 10-20%... Means of monitoring: electrocardiogram, blood pressure, oxygen saturation, breathing rate...

Needles, gloves, gauze, alcohol, sterile tissue, spinal anesthesia needle, epidural kit... Medicines: lidocaine, bupivacaine, levobupivacaine, ropivacaine... can be combined with morphine, adrenaline, clonidine...

Pre-operative examination, explaining to the patient to cooperate. Clean the anesthetic area. Give the patient a sedative the night before surgery (if necessary).

Patients were guided by spinal ultrasound to guide the subarachnoid injection technique before undergoing spinal anesthesia.
Prevention of hypotension by placing an intravenous line and giving fluids from 5-10 ml/kg of body weight (for adults) in 2 positions:
Sitting: patient sitting with back arched, head bowed, chin resting chest, legs extended on the operating table or feet resting on the chair. Lying: the patient lies on his side with his back bent, knees pressed against the abdomen, chin pressed to the chest. Disinfect the needle puncture area 3 times with an antiseptic solution, cover the hole with a sterile tissue and conduct midline or lateral spinal anesthesia.
Midline: insert the needle into the space between the 2 vertebrae, position L2-L3 to L4-L5. Lateral line: poke the needle 1-2cm from the midline, direct the needle to the midline, up, to the front. Aim the bevel of the anesthetic needle parallel to the patient's spine and insert the needle through the dura. Check for CSF oozing, turn the bevel of the needle toward the patient's head and inject the anesthetic.

Patients are guided by spinal ultrasound to guide the epidural injection technique before the epidural procedure
Prophylaxis of hypotension by placing an intravenous line and giving fluids from 5 -10 ml/kg body weight (for adults) with 2 positions and the same puncture line for spinal anesthesia at positions L2-3, L3-4. Then, local anesthetic with 1-2% lidocaine.
Identify the epidural space by signs such as: loss of resistance, hanging drops, ultrasound (if any) and evaluate the needle is in the correct position by signs of loss of resistance and no regurgitation of cerebrospinal fluid and blood.
Turn the needle bevel towards the tip, insert the catheter slowly with a length of 2 - 6cm in the epidural space and then withdraw the Tuohy needle. Test and test with 2-3ml lidocaine 2% mixed with adrenaline 1/200.000. Secure the catheter with a sterile bandage. Drugs used are:
Lidocaine 2% 10 - 20 ml; Bupivacaine 0.25 - 0.5% 10 - 20 ml; Ropivacaine: 0.25 - 0.5% 10-20 ml; Levobupivacaine 0.25 - 0.5% 10 - 20 ml. Combination drugs:
Morphine 30 - 50 mcg/kg; Sufentanil 0.2mcg/kg, not to exceed 30mcg/kg; Fentanyl 25-100 mcg.

Monitor vital signs: consciousness, heart rate, electrocardiogram, arterial blood pressure, capillary oxygen saturation. Check the degree of sensory and motor blockade Monitor unwanted effects of spinal anesthesia, epidural anesthesia. Remove the patient from the room when the patient regains consciousness, there are no hemodynamic and respiratory disorders, the patient is fully restored to movement, and the level of sensory block is below T12 (under the inguinal fold).

Allergies, anaphylaxis to local anesthetics: anesthetic poisoning caused by mistaken injection into blood vessels. Treatment: stop using local anesthetics, anticonvulsants, emergency respiratory and circulatory resuscitation, Intralipid infusion when poisoning with local anesthetics bupivacaine and ropivacaine. Epidural perforation: management by withdrawing the needle, changing the puncture site (above the old one) or switching to another method of analgesia. General spinal anesthesia by injection of anesthetic into the subarachnoid space: emergency respiratory and circulatory resuscitation. Patients with hypotension, bradycardia: treat with vasopressors (ephedrine, adrenalin...) atropine and fluid resuscitation. Headache, nausea and vomiting, urinary retention.

Epidural hematoma Nerve root damage, cauda equina syndrome Meningoencephalitis Epidural space abscess. In order for the technique of epidural or spinal anesthesia in endoscopic stricture ureteroscopy to be successful, the patient needs to cooperate perfectly with the doctor and medical staff to perform, and at the same time choose a suitable location. The medical facility is fully equipped with modern medical equipment.
Vinmec International General Hospital is one of the hospitals that strictly applies safe surgical anesthesia practice standards according to international guidelines. With a team of experienced anesthesiologists and nurses, along with modern equipment such as nerve detectors, ultrasound machines, Karl Storz difficult airway control system, full anesthesia monitoring system GE's AoA (Adequate of Anesthesia) interface including monitoring of anesthesia, pain and muscle relaxation will deliver high quality and safety, helping patients to have adequate anesthesia, not awake, without residual muscle relaxants. after surgery. Vinmec Health System is also proud to be the first hospital in Vietnam to sign with the World Anesthesiology Association (WFSA) towards the goal of becoming the safest hospital for surgical anesthesia in Southeast Asia.