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CASE REPORT
Year : 2007  |  Volume : 51  |  Issue : 6  |  Page : 538-540 Table of Contents     

Lumbar epidural anaesthesia for fixation of intertrochanteric fracture in a 108 year old elderly patient


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 Acceptance23-Oct-2007
Date of Web Publication20-Mar-2010

Correspondence Address:
Simant Kumar Jha
Department of Anaesthesia, Rajendra Institute of Medical Sciences, Ranchi-834009, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


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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 2020 Oct 20];51:538-40. Available from: https://www.ijaweb.org/text.asp?2007/51/6/538/61196


   Introduction Top


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 Top


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 Top


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 Top

1.Djokovic JL, Hedley-Whyte J. Prediction of outcome of sur­gery and anesthesia in patients over 80. JAMA 1979; 242: 2301-6  Back to cited text no. 1      
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  Back to cited text no. 2      
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  Back to cited text no. 3      
4.Weintraub HD, Kekoler LJ. Demographics of aging. In: McLeskey CH, ed. Geriatric Anesthesiology. Williams & Wilkins, 1997; 3-12.  Back to cited text no. 4      
5.Moraca RJ, Sheldon DG, Thirlby RC. The role of epidural anesthesia and analgesia in surgical practice. Ann Surg 2003; 238: 663-673.  Back to cited text no. 5  [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  Back to cited text no. 6      
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  Back to cited text no. 7      
8.Kapral S, Gollmann G, Bachmann D, et al. The effects of tho­racic epidural anesthesia on intraoperative visceral perfusion and metabolism. Anesth Analg 1999; 88: 402-6  Back to cited text no. 8      
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  Back to cited text no. 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  Back to cited text no. 10      
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.  Back to cited text no. 11      
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.  Back to cited text no. 12      
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  Back to cited text no. 13      


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