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Correspondence |
Cleveland, Ohio
To the Editor:
We present details of the difficult anesthetic management of a 106-yr-old patient scheduled for hip replacement surgery. A 106-yr-old, 54 kg female with severe osteoarthritis of the right hip was scheduled to undergo total hip replacement. Multiple attempts to achieve dural puncture for spinal anesthesia were unsuccessful due to severe vertebral column deformity. General anesthesia was induced with etomidate 6 mg, fentanyl 50 µg, and tracheal intubation was facilitated with 100 mg of succinylcholine.
The patient was returned to the supine position at the conclusion of the surgery. After positioning, the oxygen saturation dropped to 90%. The desaturation persisted despite 100% oxygen. Lung auscultation revealed no breathing sounds on the left. The endotracheal tube (ETT) was noted to be taped in the same position as after induction, but because the patient was edentulous with loose soft tissue around the mouth, the ETT with the lips had entered the oral cavity, resulting in a right main stem intubation. The ETT was pulled back and the oxygen saturation returned to normal. The patient was extubated and was transported to the postanesthesia care unit, discharged to the regular nursing floor on postoperative day (POD) three and to the rehabilitation centre on POD four.
This patient presented numerous technical difficulties related to her advanced age. One of the determinants of the risk for perioperative cardiac complications is age,1 as the incidence of arrhythmia, coronary artery disease, valvular heart disease and especially aortic stenosis increases with age.2
It can be difficult to perform neuraxial anesthesia in the geriatric age group. It is more common to see excessive ossifications, scoliosis, kyphosis and decreased flexion of the spine due to osteoarthritis.3 Calcification of the ligaments can prevent dural puncture.4 These modifications explain our inability to perform spinal anesthesia in this elderly lady.
Hypoxemia occurred with repositioning of the patient. The increase in mobility of facial structures allowed the ETT to move endobronchially. In addition, with increasing age the chest becomes stiffer because of calcification and arthritic changes in the ribs and spine, and the respiratory muscles fatigue more quickly.5 Hypoxia will occur more often and faster compared to the younger adult. There is an overall loss of expiratory flow rate, increased airway resistance, and decreased compliance of the pulmonary system. Changes in the physical composition of the lung parenchyma also reduce the efficacy of gas exchange in the aging lung. All these factors may have contributed to the observed hypoxemia.
References
1 Detsky AS, Abrams HB, Forbath N, Scott JG, Hilliard JR. Cardiac assessment for patients undergoing non-cardiac surgery. A multifactorial clinical risk index. Arch Intern Med 1986; 146: 2131–4.[Abstract]
2 Amar D, Zhang H, Leung DH, Roistacher N, Kadish AH. Older age is the strongest predictor of postoperative atrial fibrillation. Anesthesiology 2002; 96: 352–6.[Medline]
3 Sprung J, Bourke DL, Grass J, et al. Predicting the difficult neuraxial block: a prospective study. Anesth Analg 1999; 89: 384–9.
4 Tessler MJ, Kardash K, Wahba RM, Kleiman SJ, Trihas ST, Rossignol M. The performance of spinal anesthesia is marginally more difficult in the elderly. Reg Anesth Pain Med 1999; 24: 126–30.[Medline]
5 Allen SJ. Respiratory consideration in the elderly surgical patient. Clin Anesthesiol 1986; 4: 899–904.
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