Recommended Citation
Patel A, Gaiha R, Sumar M, Knezevic N. Breaking age barriers: Neuroaxial anesthesia for intramedullary rod insertion of right femur in a 99-year-old patient. 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: Neuraxial anesthesia is a commonly utilized technique for lower extremity surgeries by offering significant benefits such as reduced cardiovascular and respiratory risks compared to general anesthesia. Femoral rod fixation often poses unique anesthetic challenges in the elderly due to their advanced age, comorbidities, and reduced physiological reserves [1]. For a 99-year-old patient, extensive discussion between healthcare providers and patient’s family, as well as having a tailored anesthetic plan is crucial to optimize patient outcomes and minimize potential complications. Case Presentation: The case represents a 99-year-old female with a BMI of 18.8 and a significant past medical history of atrial fibrillation on Eliquis, sick sinus syndrome status post pacemaker placement in 2008, systolic congestive heart failure with a recovered ejection fraction of 35% to 55%, multivessel coronary artery disease, tricuspid valve regurgitation, pulmonary hypertension with a PASP of 60 mmHg, chronic kidney disease, hypertension, GERD, hypothyroidism, hyperlipidemia, and legal blindness in the left eye. Patient presented for an insertion of intramedullary rod fixation of the right femur following a mechanical fall. Prior to surgery, medical and cardiac clearance was obtained, which revealed the patient’s high intraoperative risk and a NSQIP risk of mortality estimated at approximately 33.2%. From the cardiology perspective, the patient was deemed medically optimized to the best extent possible. Once clearance was finalized, discussions were held with the patient’s power of attorney (POA) to ensure alignment on the surgical plan. Initially, general anesthesia (GA) was intended for the procedure; however, significant concerns were raised regarding the patient’s cardiac history and the risks associated with GA. After thorough discussions among the surgical, anesthesia, and POA teams, it was decided to proceed with a trial of a spinal block, reserving GA as a backup if necessary. Intraoperatively, an L2-L3 spinal anesthesia was administered using the C-arm and 1.1 mL of 0.75% bupivacaine in dextrose. An arterial line was placed in the left radial artery for close blood pressure monitoring. The patient tolerated the procedure well and received a total of 75 mcg of fentanyl, 1.5 liters of intravenous fluids, and some phenylephrine boluses for blood pressure support. After the surgery, she was transferred to the PACU for monitoring where she had an uneventful recovery. Subsequently, she was discharged home later that day. Conclusion: A thorough preoperative evaluation and use of clear, closed-loop communication among the care team-including anesthesia, surgery, cardiology, and patient’s POA, are essential in ensuring alignment and addressing potential complication. Equally as important is having a well-prepared backup plan to managed unexpected situations effectively. This collaborative approach minimizes risks and enhances patient’s safety. 1. Guay, J. et al. (2016). Cochrane Database Syst Rev 22: 1-84
Type
Oral/Podium Presentation
Affiliations
Advocate Illinois Masonic Medical Center