Utilization of Continuous Spinal Anesthesia for Total Hip Arthroplasty in a Septuagenarian with Acute Myocardial Infarction.
Kelly Hyde, MD and Yong G Peng, MD, PhD
Department of Anesthesiology, University of Florida, Gainesville, Florida
There will be approximately 250,000 hip fractures in the United States
this year. Of these, 90% will occur in patients over the age of 50. These
numbers are expected to triple by the year 2050. The mortality for the
surgical repair of a proximal femur fractures is 6.2% and increases to 16%
in patients who have experienced a myocardial infarction within one year of
total hip arthroplasty (THA). Standard of care currently assumes surgical
correction of the fracture at the earliest possible time with the obvious
goal of minimizing perioperative morbidity and mortality related to
prolonged immobility.
The patient was a 73-year-old male with a medical history of congestive
heart failure, diabetes, and renal transplant, who had a displaced proximal
femur fracture after a fall. At the time of the fall the patient also
sustained a non-ST-segment-elevation myocardial infarction. This diagnosis
was supported by an increased concentration of troponin I of 18 mcg/ml and
an echocardiogram that showed global hypokinesis with an ejection fraction (EF)
of 20-25%, significantly decreased compared to previous studies in which his
EF was recorded at 40-45%. The patient was transferred from an outside
hospital, intubated and in acute renal failure with a creatinine of 2.6
mg/dl. He was admitted to the medical intensive care unit for optimization.
During his stay there he was extubated, medical therapy for his heart
failure was optimized and his renal function returned to baseline (creatinine
1.4 mg/dl). Seven days later the patient underwent bipolar hip replacement
under continuous spinal anesthesia. The patient tolerated the procedure well
and was hemodynamically stable throughout the intraoperative and immediate
postoperative period. Six days after surgery the patient underwent cardiac
catheterization and was found to have diffuse 3 vessel disease. After
catheterization, presumably as a result of contrast administration, his
renal function acutely declined. He also developed a left lower lobe
pneumonia resulting in the deterioration of his respiratory status.
Approximately two weeks following hip replacement the patient experienced
chest pain, acutely increasing shortness of breath and progressive
hypotension. Two days after the onset of these symptoms the patient died.
With an increasingly older and therefore medically more complicated surgical
population requiring THA, the issue of when to proceed to surgery and what
technique to utilize will become more difficult. Weighing the risks of
delay, such as DVT and pulmonary complications against the risks of surgery
in a patient who has recently had a myocardial infarction will remain
particularly difficult. However, this case demonstrates that adequate
medical optimization and anesthetic techniques such as continuous spinal
anesthesia appear to allow for surgical intervention in such patients
without unacceptably high immediate perioperative risk.
