Case Scenario

Shamsuddin Akhtar, MBBS, Roberto Rappa, MD, and Ghori Mohammed, MD

A 76-year-old male, Patrick, presents for a total right hip replacement. The patient has a history of osteoarthritis, chronic atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. He denies significant cardio-respiratory symptoms, his recent stress test was negative for ischemia, and ejection fraction was reported as 56%. His medications include lisinopril, coumadin, glipizide, and naproxen. He occasionally takes tramadol for moderate-to-severe pain. You are asked to see Patrick and discuss the anesthetic plan. Patrick's wife had a similar surgery under general anesthesia with an epidural for postoperative pain control. She was extremely pleased with this choice because she did not feel any pain at all after the operation. She attributes the success of the operation to the anesthetic she had. Patrick is keen to have a similar anesthetic.

Can spinal or epidural anesthesia be used for this patient?

Since the patient is on coumadin, neuraxial blockade may be contraindicated.

Spinal or epidural anesthesia is contraindicated in patients with coagulopathy. ASRA (American Society of Regional Anesthesia) guidelines generally state that the coagulation studies need to be within the normal range before elective placement of the neuraxial block. If spinal anesthesia is used for surgery, long-duration preservative-free morphine (Astramorph) can be administered intrathecally with the local anesthetic (beware of respiratory depression). Intrathecal opioids can provide pain relief for many hours after surgery. If epidural anesthesia was used, the patient could receive an initial dose of dilute local anesthetic solution with opioids and subsequently a continuous infusion of local anesthetic plus an opioid. Since the patient's INR comes back at 1.5, he undergoes the surgery under general anesthesia without spinal or epidural.

Patrick recovers from the anesthetic, but he is still not fully awake. He is maintaining his airway, breathing at a rate of 14 breaths per minute, and his saturation is 98% on oxygen. You leave him in recovery under the care of nursing staff. Half an hour later, your are urgently requested to see Patrick as he is agitated and thrashing about in bed.

What could be the reason for this?

The assessment in this situation should follow the ABCDs (airway, breathing circulation, and disability). Elderly patients are more sensitive to the depressant effects of anesthetics, sedatives, and opioid analgesics. Airway and breathing, if compromised can lead to hypoxia with accompanying cerebral hypoxia, resulting in agitation, anxiety, and confusion. Circulatory depression can lead to the same clinical picture in addition to clammy skin, sweating, and reduced capillary refill time. Postoperative cognitive dysfunction is an entity on its own in elderly population, the cause of which is still unclear. A full bladder or inadequate analgesia can also present in a similar way. On review, you find that the cause of his agitation is likely postoperative pain.

How would you manage his postoperative pain?

Pain can typically be controlled with intravenous opioids in combination with regular acetaminophen. Patient-controlled analgesia (PCA) is used if the patient is cooperative. If patient is not cooperative, IV opioids may have to be administered on as needed basis.

Hydromorphone PCA was chosen as it is more potent, has a shorter duration of action, and no active metabolites compared to morphine. As soon as the patient was able to tolerate food orally, he was started on oral pain medication. Percocet, which is the combination of oxycodone and acetaminophen is commonly prescribed after surgery. Excessive sedation can occur with opioid medication in the elderly. Hence, they should be started on lower doses and medication should be carefully titrated. He tolerated the medication and was discharged home on postoperative day #4.

However, on his postoperative visit, he is still complaining of significant pain at the operative site. His activity is limited due to pain. How will you work up this patient? What medications will you prescribe?

The persistent postoperative pain is unusual. General approach to pain is to examine the patient and confirm the diagnosis. Appropriate investigations such as radiological imaging may be needed.

Physical exam revealed limited range of motion with no apparent signs of infection. Patient underwent hip X-rays that showed a possible collection of fluid at the operative site, which was further characterized by CT scan of the hip. The fluid collection was drained, which released pressure and decreased the intensity of pain. Regular physiotherapy is very important in order to reestablish the range of movement after many orthopedic surgeries. Failure to do so can lead to contractures and worsening pain syndromes. Patrick underwent regular physiotherapy that helped the recovery process and decreased pain considerably.

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