Continuous Thoracic Segmental Spinal Anesthesia for Ovarian Cystectomy in a Patient with Recurrent Perioperative Anaphylaxis: A Case Report

Abstract

Perioperative anaphylaxis is uncommon but potentially fatal, and subsequent anesthetic management is difficult when the responsible allergen remains unidentified. Re-exposure to multiple anesthetic drugs may be hazardous, particularly after previous cardiovascular collapse during general anesthesia. Continuous thoracic segmental spinal anesthesia (TSSA) may provide a means of limiting exposure to systemic anesthetic agents in selected high-risk patients. A 46-year-old woman presented for definitive excision of a large ovarian cyst after repeated aspirations and ultrasonographic concern for a thickened, septated cyst wall. Her history included four previous anaphylactic reactions, including two episodes of severe perioperative cardiovascular collapse during attempted ovarian cystectomy under general anesthesia. Previous records documented exposure to propofol, fentanyl, midazolam, vecuronium, and cisatracurium, but the culprit allergen had not been identified. Total serum immunoglobulin E was elevated, but formal allergy testing and previous acute tryptase results were unavailable. After multidisciplinary discussion and high-risk consent, continuous TSSA was selected to minimize exposure to previously administered general anesthetic drugs, neuromuscular blocking agents, opioids, and sedatives. An intrathecal catheter was inserted at the T10–T11 interspace, and incremental levobupivacaine dosing produced a sensory block from T4 to S2. Open ovarian cystectomy through a lower midline incision proceeded uneventfully for approximately 3 h. Hemodynamics remained stable without vasopressors, and no systemic sedative, opioid, induction agent, volatile anesthetic, or neuromuscular blocking agent was required. Continuous TSSA may be considered in carefully selected patients with previous severe perioperative anaphylaxis when allergen identification is incomplete and avoidance of multiple general anesthetic agents is desirable.