Thoracic spinal anesthesia for laparoscopic peritoneal dialysis catheter placement in older high-risk end-stage kidney disease patients

Abstract

Peritoneal dialysis (PD) catheter placement is considered a controversial procedure in patients with a history of abdominal surgeries or peritonitis. In these subjects, video laparoscopic (VLS)-assisted placement under general anesthesia (GA) is the gold standard procedure. However, older multimorbid patients are at high risk for complications in GA. In our opinion, thoracic spinal anesthesia (TSA) instead of GA could also be used in older multimorbid patients undergoing PD. Here, we report five cases of older multimorbid end-stage kidney disease (ESKD) patients aged 79.6 ± 3.5 years with a history of abdominal surgery or peritonitis needing renal replacement therapy. Overall comorbidity was high (Cumulative Illness Rating Scale (CIRS) comorbidity index 4.0 ± 1.2 and CIRS severity index 2.1 ± 0.5). We placed the PD catheter in these patients using the VLS-assisted placement under TSA. All subjects underwent TSA performed at the T9-T10 thoracic level, obtaining optimal pain control and no periprocedural side effects. This is the first attempt to utilize the TSA in PD catheter VLS placement in very old multimorbid patients. Further studies could be useful to confirm whether TSA can be successfully used in VLS-assisted PD catheter placement, especially in subjects ineligible for GA such as older frailty patients.

Introduction

Older patients on peritoneal dialysis (PD) report fewer dialysis-related symptoms compared to patients on hemodialysis (HD) and benefit from hemodynamic stability, lower incidence of major adverse cardiac and cerebrovascular events, better metabolic control and hypertension management and hospital independence.^1–3 Studies show that PD patients have a higher quality of life, less stress, and fewer mood disturbances, making PD a preferred treatment for older patients with kidney failure (end-stage kidney disease (ESKD)).^4–6

However, PD catheter placement brings a risk of complications such as catheter malfunction and migration in patients with prior abdominal surgeries or peritonitis. Video laparoscopic (VLS)-assisted placement offers clear visualization to position the catheter correctly and address eventual malfunctions, but usually, it requires general anesthesia (GA), which brings risks for older, multimorbid patients. ⁷ One alternative approach to GA is regional anesthesia, like thoracic spinal anesthesia (TSA), which could minimize opioid use, mortality, major morbidity, and hospital stay length.^8,9 TSA has been widely used and appreciated for its advantages over the more classical and hitherto accepted lumbar puncture.^10–12 Radiological studies have demonstrated a wide anatomical margin of error available and the adoption of more correct puncture techniques. ¹³ Any puncture to the cord itself is shown not to lead to any particular adverse consequences necessarily.^14,15 There is no existing literature on VLS-assisted placement of PD catheters under TSA.

We chose to proceed with VLS-assisted PD catheter placement under TSA in older ESKD patients for which TSA was the only feasible option. In this work, we present five cases of older, multimorbid patients with prior abdominal surgery or peritonitis who required renal replacement therapy under TSA.

Case description

Between May and July 2022, five men aged 74–83 (mean age ± SD: 79.6 ± 3.5 years) with ESKD underwent VLS-assisted placement under TSA of the PD catheter (Swan-Neck catheter). All patients presented several comorbidities (Cumulative Illness Rating Scale (CIRS) comorbidity index 4.0 ± 1.2 and CIRS severity index 2.1 ± 0.5).

Case 1 (83 years): Patient affected by hypertension complicated by hypertrophic heart disease and multiple district atherosclerosis. He has been in Ambulatory Peritoneal Dialysis since 2017. In July 2021, he stopped PD and switched to HD due to fungal peritonitis. One year later, he chose to re-try with PD. Abdominal adhesion forced the VLS-assisted placement of the PD catheter.

Case 2 (79 years): Patient affected by Type 2 diabetes (T2D) with micro and macrovascular complications (diabetic nephropathy, retinopathy, and polyneuropathy). He started PD in June 2021. After one year, he experienced peritoneal catheter dysfunction (impossibility to discharge the dialysate) which led to the hypothesis of an omental wrap. The only solution was a VLS-assisted re-placement of the PD catheter.

Case 3 (82 years): Patient who experienced previous open cholecystectomy. He was affected by ischemic heart disease with previous cardiac revascularization and heart failure with reduced ejection fraction (HFrEF) NYHA class III and T2D. In March 2022, he experienced COVID-19-related pneumonia. The high probability of intra-abdominal adherences made us opt for the VLS-assisted placement of the PD catheter. Furthermore, he has lung damage contraindicated GA.

Case 4 (79 years): Patient affected by ischemic heart disease with previous cardiac revascularization, severe heart HFrEF NYHA class IV, T2D, peripheral artery disease (previous left carotid thrombectomy and subsequent angioplasty, obliterating arterial disease of the lower extremities with occlusion of the bilateral superficial femoral arteries). In 2014, he was submitted to an open cholecystectomy complicated by peritonitis. Also, there was an elevated probability of intra-abdominal adherence, thus we decided to use the VLS-assisted approach to place the PD catheter.

Case 5 (74 years): Patient affected by chronic obstructive pulmonary disease and lung adenocarcinoma, T2D complicated by micro and macrovascular complications. This patient was previously submitted to an open cholecystectomy. Due to the high likelihood of intra-abdominal adhesions, we decided to use the VLS-assisted approach to place the PD catheter.

Methods

Five patients underwent VLS-assisted PD catheter placement under TSA at the Unit of Nephology and Dialysis of the IRCCS INRCA Hospital, Ancona, Italy. The TSA was performed at the T9-T10 thoracic level with a 25G needle. The puncture is performed with a spinal needle only. The most correct and safe technique involves needle advances of 2 mm with a check of CSF leakage after each one. Since at the mid-thoracic level, the distance between the dura and the cord is 5–8 mm, it is virtually impossible to get to the cord with the needle's tip. The level reached by the sensory block in these cases is C3. The motor blockade is excluded by a sufficient volume of low-concentration anesthetic (0.25%) administered at a lower metameric level and thus subject to further dilution at the upper cervical level. Therefore, an exclusively sensory differential block is achieved. ¹⁶

The anesthetic used was hyperbaric bupivacaine 0.25% 10 mg. Sedation was performed with a variable-dose combination of ketamine 15–20 mg and midazolam 1–2 mg administered intrathecally before the anesthetic. Due to the achievement of C3–C5 metameres coverage, the shoulder pain often caused by pneumoperitoneum did not occur. The patient's spontaneous breathing was not affected by the high level of anesthesia since it was maintained exclusively at the sensory level. The pneumoperitoneum was created by carbon dioxide insufflation via a Varess needle, followed by the insertion of a supraumbilical video scope through one 10 mm port into the peritoneal cavity. The intra-abdominal pressure was maintained at 12 mmHg during the operation. A video laparoscope with an operative channel explored the abdominal cavity. The procedures included adhesiolysis, catheter fixation, and treatment of omental wrap as needed. In one patient we needed to perform also a total extraperitoneal inguinal hernia repair always in TSA. In all patients, the PD catheter insertion was performed using the open technique through a periumbilical incision after the port's removal and the pneumoperitoneum's resolution. To ensure the correct insertion, a final examination in VLS was done. TSA was perfect for controlling pain during a video laparoscopic assisted placement of the PD catheter and concomitant hernia repair. No delirium episodes or any respiratory or neurological side effects had followed. All the patients were discharged at home one day after the intervention.

Discussion

ESKD patients with previous abdominal surgeries or peritonitis are usually excluded from PD due to the risk of catheter complications. In complicated cases, VLS-assisted catheter placement under GA is a gold standard for PD catheter placement, but it could bring high-risk complications for multimorbid older patients. We treated five such patients with VLS-assisted PD catheter placement under TSA. In all five cases, the results were satisfactory, despite the complicated clinical picture of the older subjects. All patients showed optimal pain control and no side effects and were discharged the next day.

However, even though the thoracic TSA has been used,^11,12 it is not routinely utilized. The technique requires proper training and extreme accuracy in execution.

To the best of our knowledge, our study is the first to evaluate the TSA in PD catheter VLS placement in a population of older multi-comorbid patients with a history of previous abdominal surgery who would not be otherwise eligible for PD because of the potential harm of GA. Our experiences suggest that TSA instead of GA could be useful in older complicated cases, with a faster recovery after surgery and without any significant complications.

Considering the very small number of patients involved, further studies are needed to confirm the effectiveness and safety of the VLS-assisted PD catheter placement under TSA in older complicated ESKD subjects. This anesthetic technique should not be limited to elderly high-risk patients. This approach could be applied to any patient who needs or wants to avoid general anesthesia.