Recently I have experienced a situation during an appendicectomy. The patient was an apparently healthy young male with robust physique. We had given 3.2 ml of 0.5% bupivacaine heavy. The surgeon was too much busy with peritoneum contents and omentum and took a hopping 2 hours 20 minutes for appendicectomy. His explanation was it was a difficult one with retrocecal position.

after 40 minutes of operation the patient felt mild discomfort and nausea (but no pain in the surgical site). We gave him glycopyrrolate and ondansetron. After 5 minutes the patient vomits and requests sedation. We gave him 1 mg midazolam and 60 mg propofol. After 15 minutes patient vomits again and complains of chest pain and within a minutes his saturation level begins to fall and soon it fall to 90%. We repeated ondansetron and started mask ventilation. Patient had respiratory effort (not completely apneic) but soon saturation level decreases to 80%, and then to 70% and bradycardia starts. We gave atropine in vagolytic doses and intubate the patient on emergency basis under propofol sedation (without muscle relaxant) and after intubation we gave intermediate acting MR (atracurium) and converted it to GA.

Now what is the reason of this desaturation? Vagal stimulation (supported by concomitant brady, vomiting and chest pain)?

But some of my colleague said vagal stimulation can not cause desaturation or apneia (the patient was never completely apneic). In there opinion it may be due to drug overdose (not possible with above mentioned dosage) or tongue fall back during mask ventilation (it is a possibility though).

Any opinion?

I cannot understand why a spinal is considered at all for appendectomy. The surgery is minor, and with RSI anaesthesia is "safe". I admit that I have used spinal analgesia on occasions but these were seriously sick patients with lung disease.

Not only the "patient complains of chest pain, vomiting and even sometimes bradycardia and desaturation" are possible in appendectomy under spinal anesthesia, I have seen 1 case of assystolia in a healthy young male when peritoneum manipulation, soon treated and with no other consequences. So, I believe that anesthesia for conventional appendicectomy should be General, for patient comfort and safety.

I completely agree with Doctor Cox and don't understand the reason why You must give a spinal anesthesia to do an appendectomy in a young healthy patient, furthermore, nowadays many surgeons, like me, perform appendectomy in a laparoscopic way, so a spinal anesthesia is not applicable

I agree with both Dr. Vasquez and Dr. Cruz,

The risk of vomiting increases with an appendectomy and particularly if the patient is hypovolemic. So, a spinal further places the patient at risk of vomiting and possible aspiration. The possible cause of desaturation might have been due to aspiration of the vomitus content.

Patients with recognized difficult airways, particularly children, in a setting without expert air management providers with extensive experience with difficult airways in hospitals without ALL the "toys" necessary to manage a difficult airway should be strongly considered for spinal anesthesia.

The value and safety of RSI in 2014 is marginal.

The election of the type of anesthesia to use is under the purview of your anesthesiologist after proper evaluation of the patient. There is no single preferable method if you are individualizing and  custom tailoring your indications.

In a most wanting situation,  when  you have no anesthesiologist, you can still use local anesthetic with or without intercostal block,  with or without sedation.

You don't mention the arterial pressure of the patient. You don't mention either the level of the puncture. Anyway 16mg of heavy bupivacaine may play  games with arterial pressure if badly handled. The cascade of adverse events starts with a moderate fall in a.p. that if not promptly handled leads to bradycardia and every kind of undesired situations 

A fall in a.p. and a mild bradycardia are collateral effects of spinal anesthesia. They are not complications if promptly recognised and appropriately treated.

In our practice we usually perform thoracic continuous spinal anesthesia for major abdominal surgery in critical patients.

They are most often respiratory compromised patients, but also cardiac ones. We handle thoracic spinal anesthesia up to a T2 level without relevant problems.

We handle any kind of intestinal resection, gastro-esophageal, kidney and bladder surgery. The patients keep their spontaneous respiratory drive throughout the operation and are moderately sedated. They are fully lucid  at the end of surgery and are sent to the ward with the spinal catheter as continuous analgesia.

This is to say that spinal anesthesia has great potentiality in all situations provided that is sufficiently mastered.

This is a link to some vids of the activity at our institute 

https://www.youtube.com/c/RobertoStarnari

I don't agree that most anaesthetists think spinal anaesthesia is the technique of choice for appendicectomy and I certainly don't think that 'making it easy for us' is a good reason for something to be the favoured technique!

General anaesthesia is definitely a safe and effective technique is the vast majority of patients undergoing appendicectomy. As with any procedure, the 'best' technique will depend on the specific clinical situation as well as the skills, experience and equipment available.

Spinal anesthesia can be effective for appendectomy. The surgical technique (open or laparoscopic), the expected time for surgery and the debates in the diagnosis (hemicolectomy needed or not because of cecal malignancy or inflammatory bowel disease) are the main points for the decision besides general considerations of anesthesia.