Segmental thoracic spinal anaesthesia as part of a combinedspinal-epidural technique for opencholecystectomy in an88-year-old manwithsepsis,acute kidney injuryand prior stroke.

Abstract

Acute cholecystitis complicated by intra-abdominal sepsis,multiorgan dysfunction and stage 3 acute kidney injury poses a considerable anaesthetic challenge in elderly patients,particularly when combined with a background of prior stroke and delirium.We describe the perioperative management of an 88-year-old man admitted with vomiting,progressive weakness and altered sensorium, subsequently found to have acute cholecystitis with septic shock,bilateral basal lung crepitations,and stage 3 acute kidney injury.Given the combination of pulmonary compromise and high neurological risk from a previous cerebrovas cular accident with recent delirium,a segmental thoracic spinal anaesthesia technique—a low-dose subarachnoid block restricted to the thoracic dermatomes required for upper abdominal surgery,combined with a thoracic epidural catheter —was used in preference to general anaesthesia for open cholecystectomy,with vasopressor support to offset the residual sympathec tomy-related hypotension.The patient remained haemodynamically stable throughout a 3-hour procedure and was transitioned to epidural analgesia postoperatively.This case illustrates that segmental spinal