Thoracic continuous spinal anesthesia for high-risk comorbid older patients undergoing major abdominal surgery: one-year experience of an Italian geriatric hospital

BACKGROUND: General anesthesia is associated with high morbidity/mortality in comorbid older adults. Thoracic continuous spinal anesthesia/analgesia (TCSA) may be an alternative for major abdominal surgery. We report a one-year experience of the use of TCSA in an Italian geriatric center. METHODS: Retrospective review of case notes of high-risk older patients (ASA class ≥III) who underwent TCSA for major abdominal surgery between May 2017-May 2018. TCSA was performed with a 21-gauge Tuohy-shaped spinal needle and a 24-gauge catheter (level of insertion between T6-7 and T10-11). Hyperbaric bupivacaine or levobupivacaine (two boluses of 2.5 mg) plus fentanyl (10-25 mcg) were injected before incision, followed by additional doses if needed. Intrathecal levobupivacaine plus fentanyl were infused for 72 hours after surgery. We described the anesthesiological management and evaluated the incidence of postoperative complications. RESULTS: N=90 (age = 84.4±6.9 years, males = 53.3%). High comorbidity, according to the Geriatric Index of Comorbidity, was found in 64.4% of patients. Mean Metabolic Equivalents were 2.58±0.99. Switching to general anesthesia was required in one case. Intra-operative noradrenaline (0.17±0.12 mcg/kg/min) was required in 70.6%. Additional intravenous paracetamol or weak opioids were required in 23% and 2.2% of patients, respectively. No direct complications of TCSA were reported. Cardiac, respiratory and surgical complications occurred in 15.6%, 13.3% and 13.3% of patients, respectively. Delirium occurred in 14.4%. Hospital mortality was 5.6%. CONCLUSIONS: TCSA may be a valid alternative to general anesthesia in high-risk older patients undergoing major abdominal surgery. Further studies are needed to confirm its safety and benefits.