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Sequential combined spinal-epidural anaesthesia (CSE) for femoral fracture surgery in elderly patients
Abstract
Objective: The aim of this study is to report our experience with sequential CSE for femoral fracture surgery in terms of anaesthesiological technique, clinical efficacy and tolerability with low dose isobaric levobupivacaine and suphentanyl in elderly patients. Methods: 120 patients (62 women and 68 men; mean age 78.54 ± 6.48 [62-90] years) ASA scores II-IV undergoing femoral fracture surgery with CSE anaesthesia were considered. They received 5 mg isobaric levobupivacaine 0.5% plus 2.5 μg suphentanyl plus 2.5 μg clonidine via the subarachnoid route and 25 mg isobaric levobupivacaine 0.5% epidurally, all preceded by intravenous infusion of 10 mL/kg Ringer's lactate solution. Variations in arterial blood pressure related to sympathetic blockade guided ephedrine administration. Results: Conversion into epidural anaesthesia was required only in two cases (1.66%). Seven patients (5.8%) complained of pain towards the end of operation and 9 patients (7.5%) of discomfort due to the operative position on the orthopaedic bed. Twenty-two patients (18.3%) required concentrated blood cell transfusion. There were no postoperative reports of post-dural puncture headache. Conclusions: Sequential CSE anaesthesia effectively offers a positive benefit-to-side-effect balance. Postoperative pain abolition decreases the incidence of, especially, respiratory complications. It reduces time in bed and thromboembolism incidence.
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We selected 20 matched pairs of patients who had had total hip arthroplasty by the same surgeon using the same cemented technique. Matching was by age, sex, height, weight and diagnosis. One of each pair had received hypotensive epidural anaesthesia, with less than 300 ml blood loss: the other had normotensive general anaesthesia with more than 500 ml of blood loss. Early postoperative radiographs were evaluated independently by three blinded observers, using a scoring criteria which assessed the quality of the cement-bone interface. The results showed that patients who had received epidural anaesthesia had significantly better radiographic scores (p less than 0.02). Our findings suggest that hypotensive anaesthesia facilitates penetration of cement into bone.
To investigate whether the use of methylmethacrylate cement causes hemodynamic or pulmonary instability during total shoulder replacement surgery.
Prospective, nonrandomized study.
Operating room.
9 ASA physical status I and II patients.
A 20-gauge radial artery catheter was placed in the wrist opposite the surgical site. Sedation with midazolam was provided, and a pulmonary artery catheter was placed through an 8.5-Fr introducer into the patient's right internal jugular vein.
Before induction of anesthesia, systolic, diastolic, and mean arterial blood pressures; heart rate; central venous pressure; systolic, diastolic, and mean pulmonary artery pressures; pulmonary capillary wedge pressure; and thermodilution cardiac output measurements were obtained. Arterial and mixed venous blood gas samples also were collected and analyzed for calculation of Qs/Qt. These hemodynamic and pulmonary parameters were measured again just before cementing of each prosthesis with methylmethacrylate cement and at 1, 5, 10, and 20 minutes after cementing. There were no statistically significant changes in any of the measured hemodynamic parameters at any time. There was no statistically significant difference in the calculated intrapulmonary shunt fraction.
In this study population, the use of methylmethacrylate for total shoulder replacement was not associated with adverse hemodynamic events or increased intrapulmonary shunting.