A Hip Outlook on Neuraxial: A Case Report Examining a Total Hip Arthroplasty Performed Under Continuous Spinal Anesthesia
Zainab Agboola, Asaf Gans, Carrie Atcheson, John Ahn
Department of Anesthesiology and Perioperative Medicine, Regional Anesthesia
University of Alabama at Birmingham

Case Presentation

87 yo M had a fall from standing due to syncope resulting in a periprosthetic left femur fracture

PMH: CAD (s/p 3-vessel CABG, HFpEF (55-60%), Aortic stenosis (mean gradient 19 mmHg, aortic valve area 1.2cm²), 4.9 cm ascending aortic aneurysm, CKD, HTN

Hospital course prior to DOS:

Day 0: Admitted to hospital

Day 1: Surgery cancelled; hypotension and NSTEMI; Cardiology consulted; Managed with blood and fluid administration

Day 7: Recent apixaban use; high risk of epidural hematoma with neuraxial; proceeded with surgery under general anesthesia; aborted for intolerance of minimal anesthesia

Day 12: LHC with patent grafts; Mean gradient across aortic valve 21 mmHg; No indication for balloon aortic valvuloplasty; Not a candidate for transcatheter aortic valve replacement; Cleared for surgery from cardiac standpoint

Perioperative Risks and Considerations

Anesthestic Options

Perioperative Course

Discussion

Higher mortality in nonoperative hip fracture patients compared to those in operative cohort

17.1% vs 4.4% in-hospital, 31.4% vs 10.2% at 30 days, and 48.5% vs 19.9% at 1 year^1,2

Ideal modality of anesthesia for geriatric hip fracture surgery? Unclear

Benefits of neuraxial compared to general anesthesia

↓ blood loss, ↓ incidence of thromboembolic disease, ↓ effects on pulmonary function3,4

Improvement of postoperative analgesia

May only be seen in critically ill patients5

Continuous spinal anesthesia was the anesthetic of choice because:

Greater hemodynamic stability

Rapid and more reliable onset

Better control of anesthetic level

Without sympathetic activation of intubation

Without respiratory effects of mechanical ventilation

Allows for titration of small amounts of local anesthetic

Minimizes changes expected with single shot techniques

Summary Statement

Total hip arthroplasty is preferred management for hip fractures

Risks of cardiopulmonary events and death

Decision to proceed must be balanced with surgical and anesthetic risks and patient's goals of care

Poor outcomes can still occur postoperatively despite careful perioperative planning and successful surgery

References