Urgent femoral fracture repair in a 106-year-old oxygendependent patient with pulmonary hypertension
Recommended Citation
Siddiqui A, Martinez E. Urgent femoral fracture repair in a 106-year-old oxygendependent patient with pulmonary hypertension. Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Presentation Notes
Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Abstract
Introduction: Anesthetic management in very elderly patients with multiple comorbidities presents unique challenges. In this population, preserving cardiopulmonary stability and minimizing cognitive decline are paramount. Strategies that maintain spontaneous ventilation and maintain strict hemodynamic control can significantly impact perioperative outcomes. Case Presentation: 106-year-old female with a complex past medical history—pulmonary hypertension (pHTN) with elevated right ventricular systolic pressure (RVSP), oxygen-dependent COPD, HTN, HLD, prior CVA, CKD, Alzheimer’s dementia, and MDD following a fall at her care facility presented for urgent proximal femur repair. Her candidacy for neuraxial anesthesia was poor due to receiving a dose of prophylactic enoxaparin. Additionally, the patient was acutely anemic, prompting pre-induction arterial line placement for continuous blood pressure monitoring. Given her advanced age, oxygen dependency, and significant pHTN with elevated RVSP, the plan favored a laryngeal mask airway (LMA) insertion over endotracheal intubation to preserve spontaneous ventilatory drive. It took multiple attempts to find an appropriate model of a LMA to provide adequate ventilation, however an AirQ size 3.5 was found to seat well. This approach was also chosen to avoid controlled positive pressure ventilation modes (PPV), which could potentially worsen right heart function and exacerbate pHTN. Total intravenous anesthesia (TIVA) was administered with bispectral index (BIS) monitoring used to titrate adequate anesthetic depth and mitigate the risk of postoperative cognitive dysfunction. The patient was hemodynamically stable throughout the case and uneventfully extubated without complications in the postoperative period. Conclusion: This case highlights the importance of tailoring anesthetic strategies for elderly patients with significant cardiopulmonary comorbidities. The use of an LMA allowed for maintenance of spontaneous ventilation, avoiding the potential adverse effects of PPV on right heart function and pHTN. The added benefit of an AirQ LMA was that it provided a route of intubation should there be a need for urgent endotracheal intubation intraoperatively. A BIS-guided TIVA technique provided effective anesthetic maintenance while minimizing the risk of cognitive decline associated with inhaled agents and avoiding anesthetic overdose. 1. Duggappa DR, Rao GV, Kannan S. (2015 Sep). Indian J Anaesthesia. 59(9):574–583 2. Ortega, R. Connor, C et al; (January 2013) Advances in Pulmonary Hypertension 12 (1): 18–23
Type
Oral/Podium Presentation
Affiliations
Advocate Illinois Masonic Medical Center