Spinal Anesthesia Alone for Perineal Surgery in an Austere Shipboard Setting: A Case Series on Enhancing Safety and...

Surgical anesthesia planning in an austere setting requires consideration of material resources, personnel resources, and potential complications of the anesthetic approach into consideration. When considering best practice for the austere surgical environment, the definition of safety and efficiency changes as finite resources without reliable supply chains and limited personnel in both number and scope define these settings. With a particular emphasis on anesthetic safety, we present our case series on a United States forward deployed warship comparing spinal anesthesia (SA) with and without monitored anesthesia care (MAC) for prone perineal operations in a shipboard medical department over a period of 8 months.

Patients requiring perineal surgery although deployed on a U.S. Navy warship with a single general surgeon and single certified registered nurse anesthetist (CRNA) were treated with either MAC, SA plus MAC, or SA alone for their operative anesthesia. All surgeries were performed in the prone position. Adverse respiratory and hemodynamic events were compared between anesthetic approaches. The use of limited consumable resources was also noted between groups.

Ten patients underwent prone perineal operations during the 8-month deployment period at sea. Four patients underwent SA alone and 6 patients had either MAC alone, or SA plus MAC. No patients in either group experienced hypoxic episodes or hypoventilation. In the SA group, no incidents of hypotension or need for supplemental oxygen were observed, although the MAC group had 1 episode of hypotension, and 4 of 6 (67%) MAC patients required supplemental oxygen during the procedure. SA was used in 4 of 6 (67%) of MAC patients. There was no correlation between SA and supplemental oxygen requirements.

We demonstrate real-world feasibility and efficacy of SA alone for perineal operations in an austere shipboard environment. In a setting with a single surgeon and single CRNA, SA alone for infra-umbilical surgeries provides adequate anesthesia and superior cardiopulmonary safety when compared with MAC. SA alone also utilizes fewer consumable and personnel resources when compared to MAC, making it ideal for the austere setting with limited, non-replenishable material and personnel resources. This clinical approach not only benefits the operative patient, but also the medical department by decreasing the use of often non-replenishable consumable resources.