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Anaesthesia for hip fracture surgery in a 100-year old
Anaesthesia for hip fracture surgery in a 100-year old Banu Cevik BJA: British Journal of Anaesthesia, Volume 117, Issue eLetters Supplement, 11 October 2016 DOI: https://doi.org/10.1093/bja/el_13688 Published: 01 April 2016
Due to developmenst in medical science and prolonged life expectancy global aging is increasing. Regardless of their geographic location, the 80 or over age group is growing faster than any younger age groups in the older population [1]. The number of people aged 80 years will almost quadruple to 395 million between now and 2050 [2]. According to the 2013 Turkish Statistical Institute, the proportion of older people in the total population is 7.7% [3]. Falls are a major problem for the elderly and because of the age-related comorbidities the perioperative period is a challenge. We report the case of 100-year-old female patient with hip fracture operated under spinal anaesthesia and discharged home 3 days after surgery.Written informed consent was obtained from the patient for publication of this case report and patient's data.
Case report A 100-year-old ASA II female was admitted to hospital with a right hip fracture. Laboratory findings were uneventful except anaemia (Htc:27.4%,Hb: 8.7 g/dL) and hypoproteinemia (2.9 g/dl). Chest X-ray and electrocardiogram (ECG) revealed no pathologic findings. She had no history of hypertension, cardiac disturbances or diabetes mellitus and the patient was hemodynamically stable. Coagulation tests were within normal limits and spinal anaesthesia was recommended to patient. We obtained
informed consent and discussed the anaesthetic management with the patientand her family. After correction of anaemia with 2 units of packed red blood cell (HTC:31.4 %, Hb:10.4 g/dL),the operation was scheduled. Following non-invasive monitorization including ECG, pulse oximetry, non-invasive blood pressure, and the patient was placed in right decubitus position for spinal anaesthesia. Prehydration was achieved with 100 ml (2 ml/kg) of crystalloid solution. After appropriate aseptic preparation, a 22 G spinal needle was inserted from L3-4 interspace and after clear drainage of cerebrospinal fluid 8 mg bupivacaine heavy 0.5% was injected. Right unilateral hemianaesthesia was achieved. Intraoperatively, 1000 ml of crystalloid and 500 ml of colloid solution was administered. The patient was sedated with 2 ml of midazolam and 4 L/min oxygen was delivered via face mask. The level of sensory block was T12 and motor blockade was grade 3 on the right lower limb. The surgical procedure lasted approximately 90 minutes without any hemodynamic incompetence. Patient was followed in post-anaesthesia care unit for 2 hours until the recovery on sensory and motor block. There was no analgesic requirement and the patient was discharged to Orthopaedic Service.After 3 days, the patient's laboratory evaluation and clinical condition remained stable. There was no problem related the surgical site so the patient discharged to home after 7 days of her hospital admission.
Discussion The total number of hip fractures is expected to exceed 6 million by the year 2050. According to data from the United States Agency for Healthcare Research and Quality (AHRQ) approximately one-third of fracturepatients received hip replacement and the estimated cost is 10.3 to 15.2 billion dollars per year [4]. In Turkey, hip fracture rate is lower than European countries but during the last 20 years the incidence continues to increase gradually [5]. The patient's general status and co-morbidities are the main subjects to determine the anaesthetic procedure. Large randomized studies failed to show any great difference
in outcome between general and regional anesthesia in hip fractures. The evidence for anaesthetic intervention remained poor and multidisciplinary national research studies were recommended [6]. Aging is associated with several physiological changes affecting the perioperative period. Our patient has no serious clinical problems except anaemia and mild hypoproteinemia. According to World Health Organization, on admission to hospital approximately 40% of hip fracture cases reveal anaemia. This may be the result of haemorrhage from the fracture, malnutrition or secondary to chronic diseases [6]. Blood transfusion in elderly patients is a controversial issue affecting outcome of the patients. Minimal difference has been reported between liberal (Hb>10 g/dl) and restrictive transfusion strategy (Hb<8 g/dl) in elderly patient after hip surgery [7]. We replaced 2 units of red blood cell to our patient so there was no requirement of transfusion both intra and postoperative period. Pre-hospital malnutrition is another issue in older patients and usually plays an important role in outcome. Aging process changes body compositionand many factors such as decreasing in taste and smell acuity, deterioration of dental health, decreasing in physical activity affect thenutritional status. Malnutrition is a serious common health problem especially in older people and preventive measures are inevitable [8]. Both central and peripheral nervous system degeneration in advanced age the characteristics of neural block and pharmacology of local anaesthetic agents are the other controversial topics. A reduction in the number of neurons within the spinal cord and deterioration of myelin sheets and connective tissue barriers, anatomical deformation in spine, reduction in the volume of CSF and the slowing of conduction velocity in peripheral nerves alter the characteristics of subarachnoid administration of local anaesthetics. Because of the baricity of solution, hyperbaric solutions provide a higher sensory block and quicker onset time of motor block in older patients [9]. We administered low-dose (8 mg) hyperbaric bupivacaine solution to intrathecal space and this amount provided sufficient sensory and motor block to the patient throughout surgical procedure. In conclusion, living to 100 years or more is becoming more common. Pre-anaesthetic evaluation must be based on identification of risk factors, the presence of comorbidities, general condition of the patient and optimization of medical status.
References 1. World Population Ageing 1950-2050. www.un.org/esa/population (Cit: 14.12.2015) 2. WHO: World Health Organization http://www.who.int (Cit: 14.12.2015) 3. Turkish Statistical Institute http://www.turksat.gov.tr (Cit: 14.12.2015) 4. Hip fractures in adults. www.uptodate.com (Cit: 16.12.2015) 5. Tuzun S, Eskiyurt N, Akirmak U, et al; Turkish Osteoporosis Society. Osteoporos Int 2012; 23(3):949-55. 6. Maxwell L, White S. Anaesthetic management of patients with hip fractures: an update. Contin Educ Anaesth Crit Care Pain 2013; February 26:1-5. 7. Carson JL, Terrin ML, Noveck H, et al; FOCUS Investigators. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011,29; 365 (26):2453-62. 8. Hickson M. Malnutrition and ageing. Postgrad Med J 2006; 82: 2-8. 9. Tsui BC, Wagner A, Finucane B. Regional anaesthesia in the elderly: a clinical guide. Drugs Aging 2004; 21: 895-910.
Conflict of Interest:
Due to developmenst in medical science and prolonged life expectancy global aging is increasing. Regardless of their geographic location, the 80 or over age group is growing faster than any younger age groups in the older population [1]. The number of people aged 80 years will almost quadruple to 395 million between now and 2050 [2]. According to the 2013 Turkish Statistical Institute, the proportion of older people in the total population is 7.7% [3]. Falls are a major problem for the elderly and because of the age-related comorbidities the perioperative period is a challenge. We report the case of 100-year-old female patient with hip fracture operated under spinal anaesthesia and discharged home 3 days after surgery.Written informed consent was obtained from the patient for publication of this case report and patient's data.
Case report A 100-year-old ASA II female was admitted to hospital with a right hip fracture. Laboratory findings were uneventful except anaemia (Htc:27.4%,Hb: 8.7 g/dL) and hypoproteinemia (2.9 g/dl). Chest X-ray and electrocardiogram (ECG) revealed no pathologic findings. She had no history of hypertension, cardiac disturbances or diabetes mellitus and the patient was hemodynamically stable. Coagulation tests were within normal limits and spinal anaesthesia was recommended to patient. We obtained
informed consent and discussed the anaesthetic management with the patientand her family. After correction of anaemia with 2 units of packed red blood cell (HTC:31.4 %, Hb:10.4 g/dL),the operation was scheduled. Following non-invasive monitorization including ECG, pulse oximetry, non-invasive blood pressure, and the patient was placed in right decubitus position for spinal anaesthesia. Prehydration was achieved with 100 ml (2 ml/kg) of crystalloid solution. After appropriate aseptic preparation, a 22 G spinal needle was inserted from L3-4 interspace and after clear drainage of cerebrospinal fluid 8 mg bupivacaine heavy 0.5% was injected. Right unilateral hemianaesthesia was achieved. Intraoperatively, 1000 ml of crystalloid and 500 ml of colloid solution was administered. The patient was sedated with 2 ml of midazolam and 4 L/min oxygen was delivered via face mask. The level of sensory block was T12 and motor blockade was grade 3 on the right lower limb. The surgical procedure lasted approximately 90 minutes without any hemodynamic incompetence. Patient was followed in post-anaesthesia care unit for 2 hours until the recovery on sensory and motor block. There was no analgesic requirement and the patient was discharged to Orthopaedic Service.After 3 days, the patient's laboratory evaluation and clinical condition remained stable. There was no problem related the surgical site so the patient discharged to home after 7 days of her hospital admission.
Discussion The total number of hip fractures is expected to exceed 6 million by the year 2050. According to data from the United States Agency for Healthcare Research and Quality (AHRQ) approximately one-third of fracturepatients received hip replacement and the estimated cost is 10.3 to 15.2 billion dollars per year [4]. In Turkey, hip fracture rate is lower than European countries but during the last 20 years the incidence continues to increase gradually [5]. The patient's general status and co-morbidities are the main subjects to determine the anaesthetic procedure. Large randomized studies failed to show any great difference
in outcome between general and regional anesthesia in hip fractures. The evidence for anaesthetic intervention remained poor and multidisciplinary national research studies were recommended [6]. Aging is associated with several physiological changes affecting the perioperative period. Our patient has no serious clinical problems except anaemia and mild hypoproteinemia. According to World Health Organization, on admission to hospital approximately 40% of hip fracture cases reveal anaemia. This may be the result of haemorrhage from the fracture, malnutrition or secondary to chronic diseases [6]. Blood transfusion in elderly patients is a controversial issue affecting outcome of the patients. Minimal difference has been reported between liberal (Hb>10 g/dl) and restrictive transfusion strategy (Hb<8 g/dl) in elderly patient after hip surgery [7]. We replaced 2 units of red blood cell to our patient so there was no requirement of transfusion both intra and postoperative period. Pre-hospital malnutrition is another issue in older patients and usually plays an important role in outcome. Aging process changes body compositionand many factors such as decreasing in taste and smell acuity, deterioration of dental health, decreasing in physical activity affect thenutritional status. Malnutrition is a serious common health problem especially in older people and preventive measures are inevitable [8]. Both central and peripheral nervous system degeneration in advanced age the characteristics of neural block and pharmacology of local anaesthetic agents are the other controversial topics. A reduction in the number of neurons within the spinal cord and deterioration of myelin sheets and connective tissue barriers, anatomical deformation in spine, reduction in the volume of CSF and the slowing of conduction velocity in peripheral nerves alter the characteristics of subarachnoid administration of local anaesthetics. Because of the baricity of solution, hyperbaric solutions provide a higher sensory block and quicker onset time of motor block in older patients [9]. We administered low-dose (8 mg) hyperbaric bupivacaine solution to intrathecal space and this amount provided sufficient sensory and motor block to the patient throughout surgical procedure. In conclusion, living to 100 years or more is becoming more common. Pre-anaesthetic evaluation must be based on identification of risk factors, the presence of comorbidities, general condition of the patient and optimization of medical status.
References 1. World Population Ageing 1950-2050. www.un.org/esa/population (Cit: 14.12.2015) 2. WHO: World Health Organization http://www.who.int (Cit: 14.12.2015) 3. Turkish Statistical Institute http://www.turksat.gov.tr (Cit: 14.12.2015) 4. Hip fractures in adults. www.uptodate.com (Cit: 16.12.2015) 5. Tuzun S, Eskiyurt N, Akirmak U, et al; Turkish Osteoporosis Society. Osteoporos Int 2012; 23(3):949-55. 6. Maxwell L, White S. Anaesthetic management of patients with hip fractures: an update. Contin Educ Anaesth Crit Care Pain 2013; February 26:1-5. 7. Carson JL, Terrin ML, Noveck H, et al; FOCUS Investigators. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011,29; 365 (26):2453-62. 8. Hickson M. Malnutrition and ageing. Postgrad Med J 2006; 82: 2-8. 9. Tsui BC, Wagner A, Finucane B. Regional anaesthesia in the elderly: a clinical guide. Drugs Aging 2004; 21: 895-910.
Conflict of Interest: