A 66 year old woman underwent hysterectomy plus bilateral adnexectomy and lymphadenectomy for endometrial adenocarcinoma. Background: myotonic dystrophy type I (DM type I) or Steinert's disease, pacemaker for complete AVB, restrictive lung disease requiring nocturnal non-invasive mechanical ventilation (NIV), chronic non-viral liver disease with hypertransaminasemia being monitored by the digestive tract, hypothyroidism being treated with levothyrosine and high blood pressure being treated with candesartan. Previous surgical interventions: cholecystectomy by laparotomy 20 years ago and bilateral cataract surgery, both without complications.
- ECG: sinus rhythm. Ventricular capture of pacemaker. Complete left bundle branch block.
- Chest X-ray: restrictive pattern. Slight left pleural effusion.
- Spirometry: FEV1 0.88 l (45.3%), FVC 1.16 L (49.6%), FEV1/FVC = 0.76.
- Arterial blood gases: pH 7.44, PO2 53 mmHg, PCO2 51 mmHg, HCO3 34.6 mmol/l.
- Haemogram: Hb 11.4 g/dl, Ht 35.6%, Platelets 85x1000/μl, Leukocytes 4.6x1000/μl
- Coagulation: prothrombin activity 80%, aPTT 24.8 s.
On arrival in the operating theatre, the patient was normotensive, normothermic and with arterial oxygen saturation of 99% with 02 in nasal goggles at 3 litres per minute. Premedication with benzodiazepines was avoided.
It was decided to perform intrathecal anaesthesia with 0.5% hyperbaric bupivacaine, 9 mg, plus 5 μg of fentanyl; the technique was performed without incident. In the first hour, paracetamol 1 g iv, metamizole 2 g iv, dexamethasone 4 mg iv, dexketoprofen 50 mg iv and fluid therapy with heater were administered. During this first hour, the uterus and adnexa were resected. After 100 minutes and coinciding with the iliac and para-aortic lymphadenectomy, the patient presented pain, so it was decided to inject 10 mg of bolus ketamine (avoiding the use of benzodiazepines, morphine and propofol). A total of 40 mg ketamine was used, providing satisfactory analgesia without side effects. Ventilatory mechanics and O2 saturation remained unchanged during the operation, with the only respiratory support being the oxygen therapy she was already receiving on the ward (O2 in nasal goggles at 3 l/min).
The surgery was completed after 150 minutes without incident. In the resuscitation unit, NIV (CPAP at 5 cmH2O), bilateral percutaneous transabdominal block (TAP) (7.5 ml of 0.5% ropivacaine and 7.5 ml of 1% mepivacaine in each abdomen) and rectus abdominis block (5 ml of 0.5% ropivacaine on each side) were administered, both of which were effective. Analgesia was prescribed for the inpatient ward avoiding opioids, where she arrived three hours after admission to resuscitation.
During her stay on the ward, the patient remained stable and with controlled pain, and was discharged from hospital on the fifth day after the operation.