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Back to Journal »Local and Regional Anesthesia» Volume 14

Spinal anesthesia for bilateral lower limb surgery in an elderly patient with recent myocardial infarction and percutaneous coronary intervention using ultra-low dose isobaric bupivacaine and intrathecal injection of morphine-fentanyl

Authors: Rukewe A, Nanyalo-Nashima L, Olivier N

Published on January 22, 2021, Volume 2021: pages 14, pages 7-11

DOI https://doi.org/10.2147/LRA.S287975

Single anonymous peer review

Editor who approved for publication: Dr. Stefan Wirz

Ambrose Rukewe,1,2 Linea Nanyalo-Nashima,2 Nicola Olivier2 1 University of Namibia, Faculty of Medicine, Department of Surgery and Anesthesiology, Hage Geingob Campus, Windhoek, Namibia; 2 Department of Anesthesiology, Windhoek Central and Katutu La State Hospital, Windhoek, Namibia, protected] Abstract: An elderly female patient who was planning to undergo surgery on both lower limbs had recently suffered inferior ST-segment elevation myocardial infarction and percutaneous coronary intervention. There was also re-infarction and death Significant risks. Our index patient requires amputation of the left leg above the knee to prevent infection/progressive gangrene, and the use of a back plate for conservative treatment of right femoral fractures. We used ultra-low doses of 0.5% isotope bupivacaine 4 mg and morphine 75 μg plus fentanyl 10 μg spinal injection to provide sufficient anesthesia, effective postoperative analgesia and good postoperative analgesia for radical amputation. Hemodynamic stability. Keywords: recent myocardial infarction, percutaneous coronary intervention, elderly, double lower limb surgery, ultra-low dose, isobaric bupivacaine

Inferior ST-segment elevation myocardial infarction (STEMI) and percutaneous coronary intervention (PCI), which have recently occurred in elderly female patients, can bring significant morbidity and mortality risks if they undergo surgery early. 1 The American Heart Association/American College of Cardiology (AHA/ACC) recommends postponement of elective surgery. When emergency/emergency surgery is required, surgical intervention must be appropriately monitored and treated, and clinical evaluation must be performed through the use of multidisciplinary methods. 2 In our index patients, we identified the following risk factors: age 74 years, history of high blood pressure and smoking, STEMI and drug-eluting (Biomatrix) stent placement 14 days before, simultaneous right humeral and femoral fractures, extensive For atherosclerosis and thrombosis, it has the potential of arterial embolism, low molecular weight heparin anticoagulation treatment and simultaneous surgery of both lower extremities. Peripheral nerve blocks (PNBs) and low-dose unilateral spinal anesthesia (SA) for upper knee amputation (AKA) in high-risk patients are rarely reported, but ultra-low-dose isobaric bupivacaine intrathecal injection of morphine-fentanyl Not yet reported. 3-5 We describe here our anesthesia management for this case.

A 74-year-old female patient, weighing 45 kg and 155 cm tall, was referred to the Department of Vascular Surgery and Orthopedics Unit of Katutura Intermediate Hospital in Windhoek, Namibia. According to reports, she fell from a ladder due to fainting while taking care of the garden on August 13, 2020, and sustained fractures of the proximal right humerus and distal femur. Her left leg was found to be discolored, just below the knee. The patient admitted to smoking (over 40 pack years) and had known hypertension during treatment. Her electrocardiogram (ECG) report is: ventricular rate 78 beats/min, sinus rhythm is normal, QRS axis is normal, ST segment elevation in lower lateral leads (II, III, aVF, V5-V6), leads V1-V3 The mutual change is consistent with the lower STEMI (Figure 1). Figures 2 and 3 are computed tomography (CT) angiographic images showing right coronary artery disease before and after PCI. She implanted a drug-eluting (Biomatrix) stent, and then a cardiologist gave her subcutaneous injections of low molecular weight heparin (enoxaparin 40 mg, once every 12 hours) and aspirin 75 mg. The plan is for her to receive orthopedic care for fracture and gangrene left leg amputation before starting long-term clopidogrel. She was scheduled to perform AKA with locking plates on the left leg and right femur. After discussion with anesthesiologist, vascular surgeon, and plastic surgeon, it was decided to continue with the left AKA and use the back plate to treat the fractured femur conservatively. In preparation for the surgery, she was guided by the Numerical Rating Scale for Pain Assessment [NRS], where 0 means no pain and 10 means the most severe pain imaginable. She infused 3 units of concentrated red blood cells to correct anemia (the hemoglobin concentration increased from 6.9 g/dL to 12.7 g/dL) and 1 trillion units of platelets, increasing the platelet count from 38 x 109/L to 182 x 109/L L. Written informed consent has been obtained from the patient and his relatives to release this case report, including relevant images. The case report does not require institutional review; we have ensured anonymity in the report of this case. Figure 1 Electrocardiogram showing inferior lateral elevation myocardial infarction. Figure 2 CT angiography shows the right coronary artery disease. Figure 3 CT angiography after percutaneous coronary intervention.

Figure 1 Electrocardiogram showing inferior lateral elevation myocardial infarction.

Figure 2 CT angiography shows the right coronary artery disease.

Figure 3 CT angiography after percutaneous coronary intervention.

In the operating room, monitoring includes non-invasive blood pressure (NIBP), electrocardiogram, heart rate, and oxygen saturation (SaO2). In indoor air, the baseline heart rate is 92 b/min, BP 130/70 mmHg and SaO2 92%. We give intravenous (IV) dexamethasone 4 mg and metoclopramide 10 mg as a preventive measure for nausea and vomiting (our first choice, ondansetron is not available). Due to fractures of the right humerus and right femur, in order to make the lateral positioning tolerable, 50 micrograms of fentanyl was injected intravenously, and the most experienced anesthetist performed a lumbar puncture using a 25G pencil point Spinocan® (B Braun, Germany Melson root) needle. Intrathecal injection of 0.5% isobaric bupivacaine 4 mg and preservative-free morphine 75 μg plus fentanyl 10 μg (the total volume of the LA mixture is 1.35 mL). The patient was then placed in the supine position, and it was confirmed that the sensory block reached the L1 dermatome, and the revised Bromage score was 2 (unable to bend the knee but able to bend the knee). She received a total of 600 milliliters of Ringer's lactate solution, intravenous injection of 1 g of paracetamol, and supplemental oxygen through nasal congestion at a rate of 3 L/min, which increased SaO2 to 99%. The patient maintains hemodynamic stability throughout the application of the left AKA and right femoral backplate for 42 minutes, with a heart rate ranging from 70 to 85 beats per minute, systolic blood pressure 100-130 mmHg, diastolic blood pressure 50-75 mmHg. Music guarantees a pleasant theater environment, and patients take water (up to 30 ml) by mouth every once in a while to moisturize the tongue. After the operation, the patient was observed in the recovery room for approximately 30 minutes and then transferred to the monitoring bed in the ward. The monitoring includes pain NRS scores, respiratory depression parameters, such as respiratory rate >10 breaths/min and SaO2 >90%. Her first request for analgesia was 6 hours after the operation, with an NRS score ranging from 0/10 to 3/10, controlled by oral codeine-paracetamol tablets. She was discharged from the hospital on the 11th day after surgery and was in stable condition.

This case report shows that for high-risk patients receiving AKA, the ultra-low-dose bupivacaine-opioid combination is a viable option to provide effective surgical anesthesia and postoperative analgesia, while destroying hemodynamics Minimize. Peripheral nerve block (PNB) and low-dose unilateral spinal anesthesia have been proven to provide satisfactory anesthesia and good hemodynamic stability, through some case reports and case series studies that accepted AKA. 3-7 Our test case has been arranged for bilateral lower extremity surgery, because the risk of local anesthesia systemic toxicity (LAST) is greater, so high-pressure bupivacaine cannot be used for unilateral spinal block or PNB. In addition, although the femur, lateral femoral skin, obturator nerve (anterior and posterior) and sciatic nerve are targeted respectively when the LA volume and concentration are close to the maximum safety threshold, complete analgesia/anaesthesia under PNB is sometimes difficult to achieve—— Some authors admit that there is no adverse toxic effect beyond the recommended dose. 3,4

Although Moreira et al.8 hypothesized that the anesthesia method has no significant effect on the perioperative outcome after major amputation of the lower extremity in elderly patients with impaired functions, we believe that general anesthesia (GA) is best avoided because it can easily cause hemodynamics obstacle. Instability due to increased stress response, increased myocardial irritability, and decreased systemic vascular resistance. Traditional spinal anesthesia has always been considered the gold standard method for lower extremity surgery, but many authors agree that it is best to avoid using it in patients with poor cardiovascular reserve because it may cause severe hemodynamic disturbances. 4,9 Our ultra-low-dose technology helps us maintain MAP and avoid spinal cord hypotension associated with perioperative adverse cardiac events. 10 Use ultra-low-dose intraspinal technology to limit blocked spinal cord segments, the degree of sympathetic nerve block, and minimize the impact on systemic vascular resistance. 11 In our test case, being able to maintain MAP plus supplemental oxygen management may help maintain the balance between myocardial oxygen demand and supply.

The decision to adopt this ultra-low-dose LA-opioid technology was not light, because intraspinal anesthesia is not without risks to patients with heart disease, and we began to weigh the pros and cons. Our test patient was recently implanted with a stent due to STEMI, so he used antithrombotic drugs-low molecular weight heparin (enoxaparin) and aspirin, and needed urgent orthopedic treatment for humerus, femur and AKA fractures. We had to correct anemia by transfusion of concentrated red blood cells, correct thrombocytopenia with 1 trillion units of plasma, and stop enoxaparin for 24 hours to minimize the risk of spinal cord hematoma, thereby optimizing her condition. We believe that following the guidelines of the American Society of Regional Anesthesiology [ASRA] for regional anesthesia for patients receiving anticoagulants makes the patient's intraspinal anesthesia auspicious. 12 We carefully assign more experienced anesthesiologists to position the spine with a thin pencil-pointed needle and recognize the difficulty in positioning the patient laterally. Combined spinal epidural anesthesia (CSEA) is our second option to deal with this case, especially because it offers the possibility of using a low-dose LA-opioid combination and can extend the duration of anesthesia if needed. However, both AKA and backplate application are simple, and our single spinal anesthesia has proven to be safe, cost-effective and applicable to guidelines for the use of antithrombotic drugs in intraspinal surgery.

We added a low-dose morphine-fentanyl combination to the ultra-low-dose isobaric bupivacaine. In some countries, intrathecal combined use of hydrophilic and lipophilic opioids is a common practice. The 13-17 study reported that after 100-200 micrograms of spinal morphine was used alone, pain occurred during the operation due to a delay of 30-60 minutes of onset. Compared with morphine, fentanyl is highly fat-soluble (580:1), its effect is faster, and its rapid clearance from the cerebrospinal fluid limits its impact on intraoperative and immediate postoperative effects. The morphine-fentanyl combination actually complements their different pharmacokinetic and pharmacodynamic properties to achieve superior perioperative analgesia. Intrathecal morphine at a dose of 75 micrograms has been proven to be the smallest effective analgesic dose, and it is reported that as little as 10 micrograms of fentanyl can improve intraoperative analgesia. 13,14,16,18 Neuraxis opioids have dose-related side effects, the most worrying is respiratory depression, the others are itching, nausea and vomiting. Our low-dose intraspinal opioid combination attempts to strike a balance between optimal perioperative analgesia and reduced dose-related adverse reactions. 18 When we have to inject fentanyl 50 mcg intravenously to promote the patient's spinal positioning, we are cautious because it may increase the risk of respiratory depression even if the dose is titrated to work. The postoperative parameters monitored to exclude respiratory depression include respiratory rate >10 breaths/min and SaO2 >90%. 19 Itching, nausea, and vomiting were not observed in our patients, which are recognized complications of intrathecal opioids.

In short, we believe that the technology we used in this indicator case may be applicable to other high-risk patients.

All authors contributed to the work reported in the conception, implementation, data collection and analysis; participated in drafting and revising the article; finally approved the version to be published; agreed on the journal to which the article was submitted; and agreed to all aspects of the work Responsible.

We (the author) report that there is no conflict of interest in this work.

1. Livhits M, Ko CY, Leonardi MJ, Zingmond DS, Gibbons MM, de Virgilio C. The risk of surgery after recent myocardial infarction. Ann Suger. 2011;253(5):857–864. doi:10.1097/SLA.0b013e3182125196

2. Fleisher LA, Fleischmann KE, Auerbach AD, etc. 2014 ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation and Management of Non-cardiac Surgery Patients: A report from the American College of Cardiology/American Heart Association Practice Guidelines Working Group. J Am Coll Cardiol. 2014;64(22):e77-e137. doi:10.1016/j.jacc.2014.07.944

3. Karm MH, Lee S, Yoon SH, Lee S, Koh W. Case report: Use of ultrasound-guided peripheral nerve block during an above-knee amputation in a severely cardiovascular-impaired patient who requires continuous anticoagulation. Medicine (Baltimore). 2018; 97(9): e9374. doi:10.1097/MD.0000000000009374

4. Chandran R, Beh ZY, Tsai FC, Kuruppu SD, Lim JY. Peripheral nerve block is used for upper knee amputation in high-risk patients. J Clinical Pharmacology of Anesthetics. 2018;34(4):458–464. doi:10.4103/joacp.JOACP_346_17

5. Chuah KH, Thong CL, Krshnan H, Chan L. Low-dose unilateral spinal anesthesia for lower limb amputation in critically ill patients. Malaysian Medical Journal. 2007;62(1):81–82.

6. Bech B, Melchiors J, Børglum J, Jensen K. The successful application of peripheral nerve block in femoral amputation. Acta anesthetic scan. 2009;53:257-260. doi:10.1111/j.1399-6576.2008.01859.x

7. Chia N, Low TC, Poon KH. Peripheral nerve block for lower extremity surgery—the preferred anesthesia technique for patients with recent myocardial infarction? Singapore Medical Journal 2002;43:583-586.

8. Moreira CC, Farber A, Kalish JA, etc. The effect of the type of anesthesia on the amputation of large lower limbs in elderly patients with dysfunction. J Vascular Surgery. 2016;63(3):696-701. doi:10.1016/j.jvs.2015.09.050

9. Guay J, Choi P, Suresh S, etc. Intraspinal block for the prevention of postoperative mortality and major morbidity: an overview of the Cochrane systematic review. Cochrane database system revision 2014; 6(1): CD010108. doi:10.1002/14651858.CD010108.pub2

10. Walsh M, Devereaux PJ, Garg AX, etc. The relationship between intraoperative mean arterial pressure and clinical outcome after non-cardiac surgery is an empirical definition of hypotension. Anesthesiology. 2013;119(3):507–515. doi:10.1097/ALN.0b013e3182a10e26

11. Kuusniemi KS, Pihlajamäki KK, Pitkänen MT, Korkeila JE. Low-dose bupivacaine: comparison of low-pressure and near-isostatic solutions for knee arthroscopic surgery. anaesthetization. 1999;54(6):540–545. doi:10.1046/j.1365-2044.1999.00855.x

12. Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional anesthesia for patients receiving antithrombotic or thrombolytic therapy: Evidence-based guidelines of the American Society of Regional Anesthesia and Pain Medicine (Fourth Edition). Reg Anesth Pain Medicine. 2018;43(3):263-309.

13. Hein A, Gillis-Haegerstrand C, Jakobsson JG. Intraspinal opioids are used as analgesics during childbirth, caesarean section and hysterectomy: a Swedish questionnaire. F1000 research. 2017; 6:133.

14. Al-Kazwini H, Sandven I, Dahl V, Rosseland LA. Extending the duration of a single intrathecal labor analgesia with morphine: a systematic review. Scan J pain. 2016; 13:36-42. doi:10.1016/j.sjpain.2016.06.010

15. Carvalho B, Butwick A. Postoperative analgesia: epidural and spinal techniques. In: Chestnut D, Wong C, Tsen L, Ngan Kee W, Beilin Y, Mhyre J, editors. The principles and practice of Chestnut's obstetric anesthesia. Fifth edition. Elsevier Sanders; 2014: 621-661.

16. Sawi W, Cai YC. A comparative study of intrathecal injection of fentanyl (with or without 0.1 mg of morphine) during cesarean section on postoperative analgesia, side effects and patient satisfaction. Middle East J narcotic. 2013; 22:21-26.

17. Weigl W, Bieryło A, Wielgus M, Krzemień-Wiczyńska Ś, Kołacz M, Dąbrowski MJ. Perioperative analgesia after intrathecal injection of fentanyl and morphine or morphine alone in cesarean section: a randomized controlled study. Medicine (Baltimore). 2017;96(48):e8892. doi:10.1097/MD.0000000000008892

18. Sultan P, Guiterrez MC, Carvalho B. Neuraxial Morphine and respiratory depression find the right balance. drug. 2011;71(14):1807-1819. doi:10.2165/11596250-000000000-00000

19. Horlocker TT, Burton AW, Connis RT, etc. A practical guide for the prevention, detection and management of respiratory depression related to the administration of opioids in the spinal canal. Anesthesiology. 2009;110:218-230.

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