Continuous spinal anesthesia for TURBT in a morbidly obese patient with EF of 20%: a case report

Abstract

Background

Patients with severely reduced left ventricular function pose major anesthetic challenges. General anesthesia may cause cardiac depression and pulmonary decompensation, while single-shot spinal anesthesia can trigger sudden hypotension. Continuous spinal anesthesia (CSA), however, allows gradual dosing and improved hemodynamic stability in such high-risk patients.

Case Presentation

We report a 133-kg man with atrial fibrillation, left bundle branch block, global hypokinesia, ejection fraction (EF) of 20%, and prior pulmonary tuberculosis with lung congestion, who underwent transurethral resection of a bladder tumor (TURBT) under CSA. Using the epidural loss-of-resistance technique at L4–L5, a catheter was advanced to 12 cm (6 cm intrathecal). Incremental doses of 1 mg isobaric bupivacaine were administered every 15 minutes to a total of 5 mg. Noninvasive blood pressure was monitored every minute. Baseline BP was 154/98 mmHg and remained stable at 135/90 mmHg intraoperatively, with a heart rate of 65–75 bpm. Adequate anesthesia was achieved without vasopressor use, and recovery was uneventful (Table 1).

Conclusion

Incremental CSA with isobaric bupivacaine was safely and effectively used in a morbidly obese patient with low EF undergoing TURBT. The technique maintained hemodynamic stability throughout, suggesting CSA as a viable anesthetic option for endoscopic urologic procedures in patients with compromised cardiac function.

PLAIN LANGUAGE SUMMARY

Patients with very weak heart function can face serious risks during surgery. General anesthesia can reduce heart strength. It can also worsen breathing problems. In parallel, standard spinal anesthesia can cause sudden drops in blood pressure. Indeed, such changes can be dangerous for patients whose hearts are already severely weakened.

We describe the case of a 65-year-old man with severe heart failure, with his heart pumping function being only 20%. The latter required surgery to remove a bladder tumor in a procedure called TURBT. Instead of giving one large dose of spinal anesthesia, we used a technique called continuous spinal anesthesia. This method allows very small amounts of medication to be given slowly. This was achieved through a thin catheter placed in the lower back.

By giving the medication gradually, we were able to avoid sudden drops in the patient’s blood pressure. The latter was stable throughout the surgery and recovered without any complications.

Introduction

Patients with severely reduced left ventricular (LV) function pose significant challenges in anesthesiology and perioperative management. This is the case of patients who have a decreased ejection fraction. These individuals are more susceptible to becoming hemodynamically unstabIe during surgery. The Iatter are also more prone to develop arrhythmias and myocardial ischemia (MI) [1,2].

Table 1.

Anesthesia technique details.

Step	Description
Patient position	Sitting position; L4–L5 interspace identified
Technique	Epidural loss-of-resistance technique performed; free cerebrospinal fluid (CSF) obtained
Catheter placement	22 Gauge catheter advanced to 12 cm at the skin, with approximately 5–6 cm intrathecal placement
Local anesthetic administration	Isobaric bupivacaine 0.5% administered in 1 mg aliquots every 15 minutes, to a total dose of 5 mg
Sensory block level achieved	T10 dermatome

Anesthetic management in this population has been well-described in the existing literature. For instance, the research of Shaheen et al. [3] included 236 patients with EF = 20–35%. Among these patients—who presented for non-cardiac surgeries—74.58% received generaI anesthesia, whereas 25.42% received regional anesthesia. The overall mortality rate was only 1.27% [3]. Similarly, Senthilkumar et al. [4,5] reported successful regional anesthesia in a patient with EF = 30%.

In parallel, multiple case reports converge on the use of spinal anesthesia in patients with low EF. For instance, low-dose bupivacaine and fentanyl were successfully used in a patient with EF = 30% [5–7]. Mulugeta et al. [6] also successfully used selective spinal anesthesia in a patient with EF = 27%. The latter underwent a below-knee amputation. The procedure did not result in any complications post-op [6].

On another level, continuous spinal anesthesia (CSA) is often underutilized in patients with severe LV dysfunction. The latter allows incremental dosing of intrathecal local anesthetic by using a catheter. It also provides superior hemodynamic stability compared to single-dose spinal anesthesia [8]. Indeed, CSA enables the administration of titrated and smaller doses while extending the duration of anesthesia as needed [9]. It contrasts with traditional spinal anesthesia, which has larger doses that can cause unpredictable block height and hemodynamic instability. CSA has proven particularly beneficial for elderly patients with cardiomyopathy who are undergoing lower abdominal surgeries. CSA also showed minimal hemodynamic disturbances, whereby only 5% experienced hypotension and 10% bradycardia [10].

Despite these advantages, the literature on the use of CSA for endoscopic urologic procedures, including transurethral resection of bladder tumor (TURBT), remains scarce, as most reports emphasize lower limb or abdominal surgeries in high-risk cardiac patients.

Case presentation

A 65-year-old male (133 kg; BMI ≈ 42 kg/m²) presented for TURBT at a tertiary care medical center. His medical history included chronic atrial fibrillation, left bundle branch block, ischemic cardiomyopathy (EF 20%), global LV hypokinesia, and prior pulmonary tuberculosis with residual congestion. He was classified as ASA IV, NYHA Class III. Preoperative heart rate was 65–75 bpm (irregular), blood pressure 154/98 mmHg, and SpO₂ 95% on room air.

Preoperative preparation

The patient was optimized medically with rate-controlled atrial fibrillation and stable respiratory status. Due to limited resources, invasive arterial monitoring was unavailable; therefore, noninvasive blood pressure was cycled every 1 minute throughout the procedure. A catheter was advanced to 12 cm at skin level, corresponding to approximately 5–6 cm within the intrathecal space. This depth was selected to reduce the risk of catheter dislodgement in a morbidly obese patient and falls within commonly accepted intrathecal catheter insertion ranges (3–6 cm).

Intraoperative course

The procedure lasted approximately 70 minutes. Free flow of cerebrospinal fluid (CSF) was confirmed after catheter placement and intermittently rechecked during dosing to confirm intrathecal position (Figure 1). Gentle aspiration was performed prior to each incremental dose to reconfirm CSF return and ensure continued intrathecal positioning. The target sensory block level was T10, appropriate for TURBT. Sensory level was assessed bilaterally using pinprick sensation. In particular, sensory level and hemodynamic response were evaluated approximately 5–7 minutes after each incremental injection before administering additional doses.

Figure 1.

Continuous spinal anesthesia used during the surgery.

Noninvasive BP remained within 15% of baseline (average 135/90 mmHg), and HR remained 65–75 bpm. No vasopressors were required. Intravenous fluids were restricted to maintain line patency. Oxygen (3 L/min via nasal cannula) maintained SpO₂ > 95%. No obturator reflex was elicited.

Postoperative course

The intrathecal catheter was removed at the end of surgery. The patient was monitored in a high-dependency unit for 24 hours. Hemodynamics remained stable. There were no arrhythmias, pulmonary congestion, or neurological complications. Pain management was achieved with paracetamol and tramadol. The patient was discharged on day 4 postop. He had an uneventful recovery (Figure 2).

Figure 2.

Timeline of perioperative events.

Discussion

This case highlights CSA as a practical choice in morbidly obese patients with severe LV dysfunction (EF 20%) where both general anesthesia and single-shot spinal carry prohibitive risks.

Normal EF is considered as above 50%. Indeed, reduced EF does increase the risk of life-threatening arrhythmias, sudden cardiac arrest, and hemodynamic instability during surgery [5,11]. From this perspective, patients with reduced EF require appropriate anesthetic techniques to maintain cardiac output while avoiding myocardial depression [11]. In patients with severe multivalvular heart disease and atrial fibrillation, slow-onset epidural anesthesia with incremental dosing remains crucial. It avoids sudden preload reduction and hypotension, which in turn maintains cardiac stability.

For instance, Castro et al. [12] demonstrated successful slow-onset epidural anesthesia in a single patient with severe multivalvular disease and atrial fibrillation. This was achieved by using incremental ropivacaine boluses that maintained hemodynamic stability.

According to the existing body of knowledge, anesthetic management differs significantly in reduced EF patients. More frequently, etomidate, calcium, and phenylephrine are used. In parallel, propofol and remifentanil are used less frequently [13]. Notably, remifentanil shows differential effects, being associated with increased complications in reduced EF patients compared to protective effects in normal systolic function patients [13].

Regional anesthesia may offer advantages as a safer alternative, reducing sympathetic stress response while maintaining hemodynamic stability [5]. In particular, research demonstrates that CSA provides superior hemodynamic stability compared to single-shot spinal anesthesia (SSA), especially when it comes to high-risk patients. For instance, in the study of Saber and El Metainy [14], 52.9% of patients who received single-dose spinal anesthesia did experience severe hypotension. In contrast, in the CSA group, hypotension was not reported in any of the participants. In addition, isobaric bupivacaine is preferred over hyperbaric solutions. Indeed, the former is reported to be more controllable and has a lower risk of unpredictable cephalad spread. This can be crucial in order to avoid high sympathetic blockade and sudden hypotension. It is especially the case in morbidly obese patients, where positioning can affect block height [15,16].

Moreover, incremental dosing in CSA allows for lower doses and gradual extension of the block. It potentially limits abrupt sympathetic blockade and preserves cardiovascular mechanisms [16]. This was the case in the study of Saber et al. [14], which found zero severe hypotension episodes in CSA versus 52.9% in single-dose spinal anesthesia (SDSA) in high-risk elderly patients.

The work of Soliman et al. [17] further reinforces the efficacy of CSA. Indeed, CSA was found to produce minimal hemodynamic changes when compared to general anesthesia. This finding was significant in patients with high cardiac risk. By using CSA, these patients had a lower incidence of tachycardia, hypertension, and hypotension [18]. In addition, when compared to continuous epidural anesthesia, CSA conferred more hemodynamic stability, especially among elderly patients [18,19]. On another level, the absence of an obturator reflex in our case may be attributed to adequate blockade at the L2–L4 nerve roots achieved through controlled intrathecal spread. Gradual extension of sensory block likely prevented inadequate obturator nerve anesthesia, which is sometimes encountered with insufficient block height [19].

To note, in Japan, photodynamic diagnosis-assisted TURBT performed after oral administration of 5-aminolevulinic acid (5-ALA) is widely practiced. 5-ALA has been associated with episodes of perioperative hypotension. For instance, in the study of Kondo et al. [20], 94.3% of patients undergoing TURBT after 5-ALA administration experienced hypotension, with 1.1% requiring urgent ICU admission. This is likely related to systemic vasodilation and autonomic modulation. In such settings, anesthetic-induced sympathetic blockade may potentiate hypotensive responses. Continuous spinal anesthesia (CSA), through gradual incremental dosing, may theoretically offer greater hemodynamic control compared to single-shot spinal anesthesia by avoiding abrupt sympathetic blockade [21].

This case report adds to the existing body of literature. Indeed, it shows that CSA can be safely used for TURBT in patients with low EF. To our knowledge, previous reports depicted a limited use of CSA in patients with severe LV dysfunction, mainly for amputations and hernia repairs. Nonetheless, it is important to emphasize that the safety of CSA in our case was associated with noninvasive minute-to-minute BP monitoring, strict fluid restriction, and readiness for vasopressor support.

Conclusion

To conclude, CSA with incremental isobaric bupivacaine was successfully and safely used in a patient with low EF undergoing TURBT. In this case, anesthesia did not result in any cardiovascular compromise, despite the patient being morbidly obese. Accordingly, this approach may be considered a valuabIe option in similar high-risk cardiac patients who require endoscopic urologic surgery.

Funding Statement

This paper was not funded.

Author contributions

Mustapha Nahle: Conceptualization; Supervision; Project administration; Validation; Writing – review & editing; Final approval of the manuscript. Mohamad Akhrass: Data curation; Investigation; Methodology; Writing original draft preparation. Zakaria Tawbe: Data curation; Investigation; Resources; Writing, review & editing. Mohamad Ghandour: Data curation; Investigation; Formal analysis; Writing, review & editing. All authors have read and approved the final version of the manuscript.

Ethical approval

Our institution does not require ethical approval for reporting individual case.

Informed consent

Written informed consent was obtained from the patient(s) for their anonymized information to be published in this article.

Generative AI statement

The authors confirm that no Generative AI tools were used in the writing, analysis, or preparation of this manuscript.

Registration number of the study

Not applicable.

Previous presentation statement

This research has not been presented previously at any conference or scientific meeting.

CARE-checklist

The authors have completed the CARE Checklist, and the completed checklist is submitted as a supplementary file to ensure compliance with case report reporting standards.

Disclosure statement

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Data availability statement

The data supporting the findings of this study are available from Rafik Hariri University Hospital.

Selected highlighted references (with explanations)

• Hay R, Gupta AB. Continuous spinal anesthesia. BJA Education. 2022. [PMC][10.1016/j.bjae.2022.03.007]

Reason: A modern educational review summarizing indications, technique, and physiological advantages of continuous spinal anesthesia (CSA), directly supporting the theoretical basis of your case.

• Castro MM et al. Slow-Onset Epidural Anesthesia for Cesarean Delivery in Severe Multivalvular Heart Disease and Atrial Fibrillation. Cureus. 2025.

Reason: Demonstrates the benefit of incremental neuraxial anesthesia in severe cardiac dysfunction, reinforcing the hemodynamic principles applied in this case.

• Maile MD et al. Identification of intraoperative management strategies that have a differential effect on patients with reduced LVEF. BMC Anesthesiology. 2022. [PMC][10.1186/s12871-022-01817-z]

Reason: Provides important data on anesthetic drug selection and intraoperative strategies in reduced EF patients, highlighting why regional techniques may be preferable.

• Saber R, El Metainy S. Continuous spinal anesthesia versus single small dose spinal anesthesia in high-risk elderly patients. Egyptian Journal of Anesthesia. 2015. [CrossRef][10.1016/j.egja.2015.03.006]

Reason: Randomized controlled trial directly comparing CSA vs single-shot spinal anesthesia, showing significantly reduced hypotension with CSA. This is one of the strongest direct evidence papers supporting your case.

• Sabry Mohamed Amin & Sadek SF. Continuous spinal anesthesia for elderly patients with cardiomyopathy. Egyptian Journal of Anesthesia. 2016.

Reason: Specifically examines CSA in patients with cardiomyopathy, directly aligned with your patient’s severe LV dysfunction. Provides outcome data supporting hemodynamic stability.

• Kondo Y et al. Preoperative antihypertensives and hypotension during bladder tumor resection with oral 5-ALA administration. PLOS ONE. 2025. [PMC][10.1371/journal.pone.0319413]

Reason: Highly relevant to TURBT procedures and perioperative hypotension risk. Strengthens the urologic relevance of your manuscript and supports the argument for controlled hemodynamic techniques like CSA.