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| CASE REPORT |
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| Year : 2007 | Volume
: 51
| Issue : 6 | Page : 538-540 |
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Lumbar epidural anaesthesia for fixation of intertrochanteric fracture in a 108 year old elderly patient
Simant Kumar Jha1, Rahul DebDas1, Mukesh Kumar2, Shanti Prakash3
1 P.G.Student, Department of Anaesthesia, Rajendra Institute of Medical Sciences, Ranchi-834009, Jharkhand, India
2 M.D. Assistant Professor, Department of Anaesthesia, Rajendra Institute of Medical Sciences, Ranchi-834009, Jharkhand, India
3 M.D. Associate Professor, Department of Anaesthesia, Rajendra Institute of Medical Sciences, Ranchi-834009, Jharkhand, India
| Date of Acceptance | 23-Oct-2007 |
| Date of Web Publication | 20-Mar-2010 |
Correspondence Address:
Simant Kumar Jha
Department of Anaesthesia, Rajendra Institute of Medical Sciences, Ranchi-834009, Jharkhand
India
 Source of Support: None, Conflict of Interest: None  | Check |
Perioperative morbidity and mortality in elderly patients continues to be an important problem.As the patient was 108 year old, it was a rare case to be reported. Seeing his age & compromised cardiac function we planned for epidural anaesthesia. Epidural anaesthesia has a distinct advantage over general anaesthesia in terms of improved pulmonary & myocardial function, less chances of thromboembolism due to early mobilization, less blood loss due to lowered MAP & lastly postoperative analgesia provided through catheter, reduces perioperative morbidity and mortality. So elderly patients can have good quality of life even this age & choice of anaesthesia plays a very important role. Keywords: Elderly, Epidural anaesthesia, Mortality
How to cite this article:
Jha SK, DebDas R, Kumar M, Prakash S. Lumbar epidural anaesthesia for fixation of intertrochanteric fracture in a 108 year old elderly patient. Indian J Anaesth 2007;51:538-40 |
How to cite this URL:
Jha SK, DebDas R, Kumar M, Prakash S. Lumbar epidural anaesthesia for fixation of intertrochanteric fracture in a 108 year old elderly patient. Indian J Anaesth [serial online] 2007 [cited 2021 Mar 8];51:538-40. Available from: https://www.ijaweb.org/text.asp?2007/51/6/538/61196 |
 Introduction | |  |
Advances in anaesthetic/surgical techniques and perioperative care have substantially reduced anaesthesia and surgery related mortality [1],[2]. However, overall mortality in the general population remains at 1.2%, 2 compared with 2.2% in patients aged 60-69 yrs, 2 2.9% in those 70-79 yrs, 2 5.8-6.2% in patients over 80 yrs, [1] and 8.4% in those over 90 yrs [3] .
Among the steadily increasing population of surgical patients aged 65 yrs and older, the fastest growing sector is individuals of 85 yrs or older [4] . As a result, greater numbers of patients are presenting for surgery with age-related, pre-existing conditions that place them a greater risk of an adverse outcome, such as cardiac or pulmonary disease or diabetes mellitus. It is, therefore, not surprising that the elderly have the highest mortality rate in the adult surgical population. [2] Postoperative adverse effects on the cardiac, pulmonary, cerebral systems, and on cognitive functions are the main concerns for elderly surgical patients who are at high risk. Moracca al [5] . reported a significant reduction in the perioperative cardiac morbidity (30%), pulmonary infections (40%), pulmonary embolism (50%), ileus (2 days), acute renal failure (30%), and blood loss (30%) using an epidural technique. Epidural anaesthesia(EA) has gained popularity with the improved postoperative outcome and attenuated physiologic response to surgery.
| Case report | | |
A 108-year-old male [Figure 1] diagnosed as a case of intertrochanteric fracture was posted for internal fixation by dynamic hip screw. On examination, the patient was weighing 65 kg, 170 cm height, had a pulse rate of 70 beats per minute & blood pressure of 140/90 mm of Hg in supine position. He was conscious and oriented in time, place and person. Patient had not given the history of chest pain or dyspnoea. His investigation revealed haemoglobin, creatinine, TLC, DLC, were in normal range. Serum sodium was 130 m Eq.liter -1 . His random blood sugar was 96 mg%. Chest x-ray was showing mild emphysematous changes. Electrocardiogram showed ST segment depression of 1 mm and T wave inversion in chest leads V1 & V2. Echocardiography showed no regional wall motion abnormalities except for left ventricular dilatation and LVEF 52%. In view of extreme old age & ischaemic changes findings in ECG, an epidural anaesthesia was planned. The procedure was explained to the patient. He was kept nil by mouth for 8 hours & was given 0.5 mg of alprazolam orally the previous night & was premedicated with 10 mg of metoclopramide & 150 mg of ranitidine orally 2 hours before operation. In the anaesthesia room an intravenous access was secured with 18 G cannula in his left hand under local anaesthesia. After applying routine monitors, patient was placed in sitting position with legs hanging by the side of OT table & supported on a foot rest and 18-G Tuohy needle was inserted via a paramedian approach into the L4-5 interspace using the loss-ofresistance technique. A multi-orifice epidural catheter was inserted via the Tuohy needle, and placed 5 cm cephalad. After the test dose, titrated dose of total 16 ml of drugs (8 ml lidocaine 2% + 5 ml of 0.5% bupivacaine + 3 ml of diluted 1 mg of butorphanol) was given through catheter. Block was checked to be achieved up to sensory level of T8. The procedure lasted for one and half hours.
Intravascular volumes were maintained by giving crystalloids that included Ringer lactate & normal saline solutions. Intraoperatively, patient remained haemodynamically stable throughout the procedure except for one point of time when BP came down to 80/40 mm of Hg, which was managed by giving 200 ml of crystalloid fluid and intravenously 6 mg of ephedrine. Throughout the procedure patient was continuouslymonitored with ECG for ischaemic changes. No untoward complication occurred throughout the course of operation except for the episode of hypotension.
Postoperatively, the patient was monitored in the recovery room for return of leg movement, neurological problems, cognitive dysfunction, respiratory difficulties & any cardiac complications. Patient did well postoperatively and he was discharged from hospital after one week.
| Discussion | | |
Epidural anaesthesia requires a cooperative patient and should have the physiological reserve to lie still for the duration of surgery. Epidural analgesia reduces the incidence of postoperative atelectasis and pulmonary infection relative to general anaesthesia in patients over 80 years of age [6],[7] .
Thoracic epidural anaesthesia in vascular surgery, coronary artery bypass grafting, and abdominal surgical procedures appears to provide greater benefit than the other techniques as it attenuates the perioperative stress response, improves myocardial oxygenation, reduces the release of troponin T, and effectively controls refractory unstable angina pectoris as a result of sympatholysis [8],[9],[10]. In addition, spinal and epidural anaesthesia inhibit the endocrine-metabolic and inflammatory response with protein catabolism and improve postoperative catabolism [11]. One of the major advantages of EA is the lower incidence of postoperative thromboembolism due to peripheral vasodilatation and the maintenance of venous blood flow in the lower extremities [11]. The suggested block height is T8 sensory level for hip surgery. With EA, the postoperative mental status is also improved immediately after surgery in the elderly, unlike the undesired reduction after GA caused by anaesthetic agents in patient with concomitant diseases. [12],[13].
On the basis of various clinical studies and observations, it must be concluded that EA has distinct advantage over general anaesthesia in presence of ischaemic changes in elderly patients. Although knowledge of the physiology ofagingshouldhelpreduceage-relatedcomplications,successfulprophylaxisis hinderedbytheheterogeneityofage- related changes, unpredictable physiological and pharmacological interactions and diagnostic difficulties.
In this case, EA with bupivacaine and lidocaine resulted in satisfactory anaesthesia with favourable effect on myocardium without morbidity even at their extremes of age. Haemodynamic stability and pain relief were established during and after the surgery. The patient was discharged to home 1 week after the surgery.
To facilitate early mobilization, improve convalescence, and reduce morbidity with decreased hospital stay, EA should be considered as a reliable anaesthetic technique compared to general anaesthesia for appropriate surgical procedures in the elderly.
| References | | |
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| 2. | Pedersen T, Eliasen K, Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital. Acta Anaesthesiol Scand 1990; 34: 176-82 |
| 3. | Hosking MP, Lobdell CM, Warner MA, Offord KP, Melton LJ 3rd. Anaesthesia for patients over 90 years of age. Outcomes after regional and general anaesthetic techniques for two common surgical procedures.Anaesthesia 1989; 44: 142-7 |
| 4. | Weintraub HD, Kekoler LJ. Demographics of aging. In: McLeskey CH, ed. Geriatric Anesthesiology. Williams & Wilkins, 1997; 3-12. |
| 5. | Moraca RJ, Sheldon DG, Thirlby RC. The role of epidural anesthesia and analgesia in surgical practice. Ann Surg 2003; 238: 663-673. [PUBMED] [FULLTEXT] |
| 6. | Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg 1998; 86: 598-612 |
| 7. | Ueo H, Takeuchi H,Arinaga S, et al. The feasibility of epidural anesthesia without endotracheal intubation for abdominal surgery in patients over 80 years of age. Int Surg 1994; 79: 158-62 |
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| 9. | Loick HM, Schmidt C, VanAken H, et al. High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting.AnesthAnalg 1999; 88: 701-9 |
| 10. | Olausson K, Magnusdottir H, Lurje L, et al. Anti-ischemic and anti-anginal effects of thoracicepiduralanesthesia versus those of conventional medical therapyin the treatment of severe refractory unstable angina pectoris. Circulation 1997; 96: 2178-82 |
| 11. | Muravchick S. Anesthesia for the geriatric patient. In: Barash PG, Cullen RK, Stoelting RK. ed. Clinical Anesthesia. 4th ed. Philadelphia, USA: LWW; 2001; pp1205-1216. |
| 12. | 12 Chung F, Meier R, Lautenschlager E, Carmichael FJ, ChungA. General or spinal anesthesia: Which is better in the elderly? Anesthesiology 1987; 67: 422-427. |
| 13. | Chung FF, Chung A, Meier RH, Lautenschlager E, Seyone C. Comparison of perioperative mental function after general anesthesia and spinal anesthesia with intravenous sedation. Can J Anaesth 1989; 36: 382-387 |
[Figure 1]
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