Imaging Guided Thoracic Epidural Catheter Insertion In A Morbidly Obese Patient Undergoing Elective Thoracotomy.


Nadia H. ISHAK1, Norliana D. MOHAMAD ALI2, Rusnaini MUSTAPHA K1, N. Izham ISMAIL3, Adli A. MOHAMMAD RAZI3, M. Zamrin DIMON3, Karis MISIRAN1

1Discipline of Anaesthesiology and Critical Care, Surgical Sciences Cluster, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Malaysia

2Medical Imaging Unit, Clinical Medicine Cluster, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Malaysia

3Discipline of Cardiovascular and Thoracic Surgery, Surgical Sciences Cluster, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Malaysia



A 26-year old morbidly obese male with body mass index of 39 kg/m2 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.


Keywords: Epidural Analgesia, obesity, morbid, computed tomography, x ray, ultrasonography.


Correspondence author: Dr. Nadia Hanom Ishak, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Sungai Buloh Campus, Jalan Hospital, 47000, Sungai Buloh, Selangor.

Tel: 03-61267069.  Fax: 03- 61267073.

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Brunei Int Med J. 2017; 13 (4): 139-143