Continuous Spinal Anesthesia for Total Knee Arthroplasty Revision in a Patient with Severe Pulmonary Hypertension

Chelsea Skinner, Janet Adegboye, Gabriel Alcodray, Sedra Hussein, Sree Kolli

 

INTRO

• Pulmonary hypertension (PH) poses significant challenges for anesthetic management

• Neuraxial/Regional anesthesia is generally preferred over general anesthesia for these patients undergoing lower extremity surgery

• Continuous spinal anesthesia (CSA) is a feasible option

 

CASE

67-year-old M with severe PH, h/o PE, OSA, super-morbid obesity who presented for knee arthroplasty revision for chronic PJI

• Large bore IV access and arterial line placed on arrival to OR

• CSA initiated: 19G catheter inserted through Tuohy needle at L3-4

• Incremental boluses of isobaric bupivacaine to achieve T12 level

• Surgery lasted ~4.5 hours

• Additional boluses of bupivacaine required

• Judicious dexmedetomidine, midazolam, fentanyl

• CSA catheter removed at end of surgery

• Post-op single-shot adductor canal block

 

DISCUSSION

Neuraxial techniques for lower extremity surgery:

Single dose spinal

• Pros: dense block, quick confirmation, reliable

• Cons: profound sympathectomy, cannot extend block

Combined spinal epidural

• Pros: dense primary block, can prolong block

• Cons: profound sympathectomy, unable to confirm proper epidural placement early

Continuous epidural

• Pros: incremental dosing

• Cons: relatively high failure rate

CSA

• Pros: low failure rate, incremental dosing, less intense sympathectomy

• Cons: risk of PDPH, cauda equina syndrome

 

CONCLUSION

• CSA is a suitable anesthetic choice for PH patients undergoing major lower extremity surgery