SUCCESSFUL CENTRAL NEURAXIAL ANAESTHESIA IN A PATIENT WITH LIFE-THREATENING CARDIAC COMORBIDITIES AND A COMPLEX PERIPROSTHETIC FEMORAL FRACTURE
ESRA Academy. Galitzine S. Sep 8, 2016; 138469; 0326 Topic: In general
Dr. Svetlana Galitzine
Dr. Svetlana Galitzine

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Abstract
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Background and Aims:

Central neuraxial anaesthesia (CNA) in cardiovascularly compromised patients remains controversial. Studies of large orthopaedic databases showed significant reduction in morbidity and mortality following CNA vs. general anaesthesia after joint replacements. Conversely, other trials found CNA to be associated with an increased risk of adverse cardiovascular outcomes.

We describe a successful CNA in an elderly patient with life-threatening cardiac comorbidities and a complex periprosthetic fracture.  

Methods:

An 83-year-old woman with previous hip and knee replacements and a distal femoral plate for an earlier periprosthetic fracture presented with a second periprosthetic fracture through the plate.
She had extensive cardiac co-morbidities including ischaemic heart disease, low ejection fraction, atrial fibrillation, pulmonary hypertension.
Her previous operation under CNA was complicated by postoperative myocardial infarction. No further cardiac optimization was possible. The patient herself and medics felt cardiopulmonary resuscitation should not be undertaken in the event of cardiac arrest.
The patient insisted on surgery, a distal femoral replacement.

Results:

Consultants-led team managed this case, with surgical and anaesthetic intervention aimed at minimising cardiovascular instability. Invasive monitoring was applied, and a combined spinal-epidural technique was performed, with an adequate spinal block achieved with 11mg of hyperbaric bupivacaine and 25mcg of fentanyl.
Propofol TCI provided conscious sedation. Surgery was complex but fast (2hr).

 Postoperative analgesia was effectively provided with a patient-controlled epidural analgesia. The patient made good recovery, with no complications. 

Conclusions:

In this challenging case good team approach and careful CNA achieved excellent outcome in a patient with life-threatening cardiac comorbidities. 

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