Anesthetic Management for Hip Fracture Repair in a Patient with Severe Pulmonary Hypertension and Immune Thrombocytopenic Purpura

• Evaluation of surgical options for patients with hematologic and pulmonary comorbidities

undergoing necessary procedures requires a comprehensive review of the risks and benefits of

anesthetic choice as well as the possible operative and postoperative outcomes for the patient.

• One of the most concerning from a pulmonary standpoint would be severe pulmonary

hypertension due to interstitial lung disease (ILD).

• Medical management of these patients with severe disease often involves prostaglandin

analogues as well as phosphodiesterase inhibitors and supplemental oxygen at home.

• Spinal anesthesia for patients with pulmonary hypertension undergoing orthopedic surgical

procedures is normally highly effective in providing adequate surgical anesthesia for patients who

are at high risk for complications from general anesthesia.

• Specific contraindications for spinal anesthesia related to hematologic disorders include

thrombocytopenia and coagulopathy (1).

• In those patients in which surgery is deemed necessary, transfusion of blood products such as

platelets or coagulation factors are initiated in order to medically optimize the patient for surgery

(5).

• In this case, we discuss a patient in which all of these factors had to be taken into consideration to

proceed with surgery.

 

63 year old female with past medical history significant for WHO Class I pulmonary arterial hypertension (PAH)

with mean pulmonary arterial pressure of 63 mmHg secondary to ILD on 7 liters of oxygen at home, coronary

artery disease with chronic total occlusion of the distal right coronary artery being medically managed, type 2

diabetes mellitus, rheumatoid arthritis, and immune thrombocytopenic purpura (ITP) who presented to a

regional hospital for 3 weeks of increasing hip pain after having tripped and fallen at home.

She was treated with oral sildenafil and treprostinil subcutaneous infusions for PAH.

Given her severe medical comorbidities, she was transferred to Cleveland Clinic Main Campus for further

management.

 

• Upon evaluation, she was found to have a displaced right femoral neck fracture.

• Orthopedic Surgery was consulted and recommended right hip hemiarthroplasty with a press-fit prosthesis to

minimize potential cement or fat emboli stress on the patient compared to a cemented stem fixation.

• Given her severe respiratory disease, it was discussed that the patient potentially may not be able to be

extubated if she received a general anesthetic and would not be a candidate for extra corporeal membrane

oxygenation. Therefore, spinal anesthesia was the best anesthetic option.

• However, one of the confounding factors was that her platelet count was 65k/uL due to her underlying ITP, so

Hematology was consulted on the morning of surgery and intravenous immunoglobulin was given as well as 2

units of platelets with appropriate rise in platelet count.

• Patient then underwent spinal anesthesia without any significant complications.

• She was given no other sedation agents and started on a norepinephrine infusion intraoperatively to treat

hypotension.

• The procedure was completed without complications and patient was transferred to the MICU postoperatively.

• Ultimately after one month, the patient was transferred to hospice and deceased related to worsening respiratory

failure.

 

• In this case, the patient had multiple medical comorbidities that presented an anesthetic challenge.

• One of the most concerning of these diseases is severe pulmonary hypertension due to interstitial

lung disease, compromising the alveolar interface due to the sequential thickening and inflammation

of the lung parenchyma as well as increased resistance in the pulmonary circulation (2).

• This presents an anesthetic challenge due to the necessity of balancing blood pressure, fluid

management, oxygenation, and acid-base physiology throughout the procedure.

• Even with best efforts to control these factors, the stress of the surgery can exacerbate pulmonary

hypertension and lead to potential complications, including arrhythmias, congestive heart failure,

myocardial ischemia, postoperative respiratory failure, hemodynamic instability, delayed extubation,

and longer length of stay in the ICU and overall hospital admission (3).

• A factor to consider was that her PAH was being managed medically through the use of sildenafil

and treprostinil subcutaneous infusion due to their pulmonary vasodilatory activity.

• Another important consideration in this case was this patient’s ITP which involved coordination with

Hematology.

• This was due to the risk of spinal hematoma in patients with thrombocytopenia which can lead to

paraplegia (1).

• Platelet counts of greater than 80k/uL are normally considered safe for spinal anesthesia to be

performed.

• However, in some circumstances, platelet counts between 50 to 80 k/uL may still allow for neuraxial

blockade (5).

• IVIG and platelet transfusions were administered immediately before surgery in this case to

minimize risk of spinal hematoma formation.

• In conclusion, when evaluating patients compromised by multiple severe medical comorbidities such

as severe PAH from interstitial lung disease and hematologic disorders such as ITP, it is important to

review the risks and benefits of anesthetic choices.

• This must be done while taking into account the goals of caring for these patients as well as the

potential complications with the surgical team.

 

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