Imaging guided thoracic epidural catheter insertion in a morbidly obese patient undergoing elective thoracotomy

A 26-year old morbidly obese male with body mass index of 39 kg/m was scheduled for an elective left thoracotomy for large loculated empyema. During pre-anaesthetic assessment, he had predictors of a difficult regional anaesthesia upon back examination such as indistinct thoracic spinous processes and intervertebral spaces. We planned for a combination of radiological imaging-assisted regional anaesthesia (mid-thoracic epidural catheterisation) and general anaesthesia for him. Prior to the procedure, the skin-epidural space distance at level T5 was measured as 8.32 cm from his transverse computed-tomography. A pre-induction ultrasound localisation of mid-thoracic spinous process and interspinous space (T5-6) was done. Epidural space was identified at the needle length of 8.5 cm (0.18 cm more than the CT-scan derived skin-epidural space estimation) and catheterised successfully, general anaesthesia with one-lung ventilation ensued. Pre-emptive thoracic epidural analgesia instituted and surgery was uneventful. Multi-modal analgesia applied and he was discharged from Intensive Care Unit four days later.

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