[Continuous spinal anesthesia for femoral fracture in two patients with severe aortic stenosis].
Service Orthopédie et Traumatologie, Département d'Anesthésie, CHU de Purpan, place du docteur-Baylac, TSA 40031, 31059 Toulouse cedex 09, France.Annales Françaises d Anesthésie et de Réanimation (Impact Factor: 0.84). 05/2006; 25(5):528-31.
Neuraxial blockade is usually not recommended in patients with aortic stenosis. However, neuroaxial blockade techniques such as continuous spinal or epidural anaesthesia can be tailored to minimize potentially dramatic consequences of decrease in systemic vascular resistance, often encountered after standard single shot spinal anaesthesia. We report the cases of two severe aortic stenosis patients (aortic valve area<0.5 cm2) that underwent hip surgery under continuous spinal anaesthesia. Small doses of isobaric 0.25% bupivacaine titrated to limit total dose below 5 mg, injected through the intrathecal catheter allowed the control of haemodynamic parameters. No clinical complication occurred in these two patients.
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ABSTRACT: The use of conduction anesthesia and induced hypotension are traditionally contraindicated in patients with aortic stenosis. This hypothesis-generating observational pilot study details the clinical outcomes in patients with aortic stenosis undergoing hypotensive epidural anesthesia for total hip replacement. From a database of 1,947 consecutive patients undergoing total hip replacement under hypotensive epidural anesthesia performed from 1994 to 2005, 22 patients were identified with aortic stenosis. Chart review was performed. All patients were monitored with central venous pressure and radial arterial catheters. Cardiovascular and renal outcomes, thromboembolic events, and blood loss and transfusion were assessed. Twenty-two patients were identified: 19 patients (86%) were American Society of Anesthesiologists classification III, and 3 patients (14%) were American Society of Anesthesiologists classification IV. The mean age was 75 years (range: 58-92). No patient suffered from preoperative angina, syncope, or resting dyspnea. Valve areas ranged from 0.9 to 1.8 cm(2) and peak gradient from 12 to 64 mm Hg. Systolic blood pressure was maintained at 60 to 100 mm Hg. The mean duration of hypotension was 91 minutes (range: 50-200). Heart rate was maintained at a mean (+/-SD) of 70 +/- 11. Central venous pressure was maintained at baseline value. Mean intraoperative crystalloid administered was 1,695 mL (range: 900-4,000), and mean estimated blood loss was 234 mL (range: 100-1,500). There were no deaths, myocardial infarctions, cerebrovascular accidents, or pulmonary embolic events. No patient developed renal dysfunction. We report the absence of complications (with calculated upper limit 95% confidence interval of approximately 13.6%) when hypotensive epidural anesthesia was performed in 22 patients with noncritical asymptomatic aortic stenosis.
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ABSTRACT: Continuous spinal anaesthesia (CSA) for laparotomy was described more than 100 years ago. Recent literature on CSA suggests that this technique can be used as a sole anaesthetic technique for laparotomy especially in patients with severe cardio-respiratory disease who would otherwise be considered unlikely to tolerate general anaesthesia or where general anaesthesia could result in a prolonged stay in the intensive care unit. This article describes how to use the technique of CSA in high risks patients undergoing laparotomy, potential problems that might be encountered and how they can be treated and prevented.