Anesthesia for Elderly Patient with Hip Fracture Case File

https://medical-phd.blogspot.com/2021/03/anesthesia-for-elderly-patient-with-hip.html

Lydia Conlay, MD, PhD, MBA, Julia Pollock, MD, Mary Ann Vann, MD, Sheela Pai, MD, Eugene C. Toy,
MD

Case 12
An 88-year-old man slipped on the kitchen floor yesterday and fractured his right hip. He is scheduled for an
open reduction and internal fixation (ORIF) of the fracture. His past medical history includes coronary artery
disease with remote coronary stent placement, congestive heart failure, and hypertension. He is not aware of
angina, and states that he sleeps on one pillow at night. However, on interview, he is noted to be mildly
confused. He is oriented to time and place, but thinks the year is 1974. He has a sedentary lifestyle, and leaves
his apartment only to go to his physician’s office, and the pharmacy. His housekeeper performs most of his
daily chores, including grocery shopping. The patient’s medications include metoprolol, clopidogrel, aspirin,
lisinopril, and simvastatin. He took NSAIDs as needed for arthritic pain prior to the fall. The patient has no
known drug allergies.

The physical examination reveals an elderly, cachectic male 5 ft 8 in tall, weighing 145 lb. His vital signs
include a blood pressure of 135/67 mm Hg, heart rate of 66, and respiratory rate of 16 with an oxygen saturation
of 98% on room air. He has a mild limitation of mouth opening, and on airway examination, his airway is a
Mallampati class 1. His heart is regular and slow, and his lungs are clear. Laboratory values include a
hemoglobin of 9.8 g/dL, a platelet count of 221,000, an international normalized ratio (INR) of 1.1, potassium
of 4.1 mEq/L, and blood urea nitrogen (BUN) of 35, and a creatinine of 1.2 mg/dL. His ECG is notable for left
ventricular hypertrophy, and his chest x-ray is normal.

➤ What are the preoperative concerns for this patient?

➤ What are the anesthetic options?

ANSWERS TO CASE 12:

Anesthesia for Elderly Patient with Hip Fracture

Summary: This is an elderly patient with revascularized coronary artery disease who presents for ORIF of a
right hip fracture.
➤ Preoperative considerations for this patient include understanding why he fell (did he trip, have a stroke, an
arrhythmia, etc.), the status of his mental function and ischemic heart disease including the possibility of stent
thrombosis, his NPO status prior to coming to the operating room, the intraoperative possibility of massive
blood loss, volume depletion, and coagulopathy.

➤ Anesthetic options: This patient can have this procedure done under general or regional anesthesia in the
form of epidural, spinal, or combined spinal epidural block. Given the dual platelet therapy, general anesthesia
is probably a safer option. There is increased risk of epidural hematoma with neuraxial anesthesia.

ANALYSIS

Objectives
1. Discuss the preoperative evaluation of an elderly patient.
2. Identify some of the choices of anesthetic technique for hip surgery.
3. List the benefits and risks of regional anesthesia and general anesthesia in the geriatric population.
Considerations
The primary issues for this patient are his confusion, his anemia, and the history of coronary artery disease and
stent placement. It is not uncommon for elderly patients to become confused, particularly as their environment
changes and they experience pain. However, since the fracture occurred as the result of a fall, it is always
important to keep in mind that the “fall” may in fact have represented another type of event. Similarly, a fall
also carries the potential for other occult injuries, including a subdural hematoma. Since a hip fracture is not an
urgent emergency, these possibilities will usually have been carefully considered prior to a patient’s coming to
the operating room. Nevertheless, they are important possibilities to keep in mind while caring for these fragile
patients.

It is also not uncommon for patients to loose a unit of blood silently into a hip fracture before coming to the
operating room. Thus, it is important to ascertain the patient’s volume status prior to induction of general
anesthesia or placement of a regional anesthetic. Blood should be available prior to surgery, and a large bore
intravenous line placed and connected to a fluid warmer. Arterial pressure monitoring in this patient allows for
beat-to-beat BP monitoring as well as enable frequent hemoglobin and blood gas assessment.

In the presence of coronary artery disease, the risk of intraoperative and postoperative myocardial ischemia
increase during periods of intense stimulation such as during induction, intubation, awakening, and in the
presence of postoperative pain. Both general and regional anesthesia can be safely achieved. However, given
the presence of both clopidogrel and quite possibly an NSAID, regional anesthesia loses favor as the risk of
bleeding outweighs the benefits of a regional technique.