Transcript Style E 24 by 48 - Advocate Health Care

Delayed Spinal Effect of Subarachnoid Blockade in a
103-years-old Female
R. F. Ghaly MD, FACS, Z. McMillan, MD, A. Lapusca, MD, N. N. Knezevic, MD, PhD, K. D. Candido, MD
Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657 USA
Abstract
Not much has been written regarding regional anesthesia in
the extremely elder population. We present a case of delayed
spinal effect of subarachnoid blockade in a 103 year old
female who presented for left hip pinning after a fall. A 25G 5
inch Pencan spinal needle was used to identify the SAS after
several attempts. Hyperbaric bupivicaine (1.5 mg of 0.75%)
with 15 mcg of fentanyl was injected into the SAS. After 10
minutes, she had not developed a level of analgesia. The
patient was placed in Trendelenburg and after 45 min
developed adequate T12 anesthesia.
Extreme elder present unique anesthetic challenges
secondary to normal physiological and musculoskeletal
deterioration. A delayed onset of neuraxial blockade in the
elderly can be related to spinal stenosis, scoliosis,
degenerative joint disease, or delayed diffusion through the
dura and should be expected prior to conversion to general for
failed SAB. In this case report, we showed that up to 45 min
may be needed for adequate surgical anesthesia.
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Introduction
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There is a paucity of literature describing regional
anesthesia in the extremely elder patient (>90 year old).
With advances in medical care and the aging baby
boomers, the prevalence of people living 95 years and
older is expected to increase.
This population presents unique regional anesthetic
challenges secondary to physiologic deterioration,
musculoskeletal contractures, degenerative joint disease,
severe neuraxial musculoskeletal degeneration, autonomic
regulatory dysfunction, cognitive dysfunction, and altered
pharmacokinetics and pharmacodynamics.
We present a case of a delayed onset of subarachnoid
blockade in a 103 year old female patient undergoing left
hip pinning of a femoral neck fracture.
Discussion
Case Description
A 103 year old obese AA female from assisted living presented for left hip pinning of a
femoral neck fracture after a fall from her wheelchair.
Preoperative evaluation revealed an elderly woman moaning incomprehensibly in
distress from discomfort.
PMH was significant for hypertension, congestive heart failure, atrial fibrillation,
osteoporosis, renal insufficiency, and right lower extremity lymphedema with cellulitis.
Preoperative labs were significant for BUN 35, CR 1.75, BNP 63, albumin 3.3, Hg 9.4,
platelets 113, and INR 1.1.
The patient was taken to the OR and placed in the right lateral decubitus position.
Approximately 500ml of NS was given as preload prior to spinal blockade. A 25G 5inch Pencan spinal needle was used to access the subarachnoid space, with free
flow of clear CSF.
Multiple attempts by an experienced (pain fellowship trained) anesthesiologist were
necessary due to severe scoliosis and osteophytes. Hyperbaric bupivacaine, 1.5 ml of
0.75% (11.25 mg), with 15 mcg of fentanyl was injected.
The patient was then placed in Trendelenburg and monitored for spinal level (Picture
1). Adequate analgesia was not reached for approximately 45 minutes at which
time she developed a level at T12.
Factors Affecting the Level of Spinal
Once a level was obtained, the surgery
Anesthesia
was uneventful and proceeded without
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Baricity
of
anesthetic
complications.
solution
Most important • Position of the patient
(during injection and
factors
immediately after
injection)
• Drug dosage
• Site of injection
• Age
• CSF fluid
• Curvature of the spine
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Drug
volume
Other factors
• Intraabdominal
pressure
• Needle direction
• Patient height
Picture 1.
• Pregnancy
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General anesthesia in the elderly has been
associated with prolonged cognitive dysfunction.
There is little information in the literature
regarding the effects of general or regional
anesthesia on patients older than 95 years.
Extremely elder patients often have multiple
significant co-morbidities including pulmonary
and cardiac disease, poor nutritional status, and
baseline cognitive dysfunction.
For these patients, regional anesthesia may be a
safer anesthetic management option.
The delayed effect of spread of local anesthetics
in our patient may be related to severe spinal
stenosis, scoliosis, or delayed diffusion through
the dura.
Patience and expected delays for spinal effect
after subarachnoid blockade is suggested.
Monitored Trendelenburg position may assist
diffusion of local anesthetic into higher levels
through stenotic regions.
Conclusion
A delayed spread of local anesthetic after
subarachnoid blockade in extreme elderly patients
should be expected, and may be secondary to
anatomical and physiological causes. In this case
report, we showed that up to 45 minutes may be
needed for adequate surgical anesthesia.
References
P. Williams-Russo, et al. JAMA. 1995;274:44-50.
A. Rodgers. BMJ 2000;321:1493
Hocking G, Wildsmith JAW. Bri J Anaesth 2004;93:568-78.
JT Moller, et al. The Lancet, 1998;351:857-61.