Anesthesia considerations in a “very old” geriatric patient for major orthopedic surgery

Sir,

As a result of large life expectancy, increasing number of geriatric patients are presenting for surgeries. Geriatric anesthesia is as challenging as pediatric anesthesia but with more variable responses and complications to anesthesia stress because of tremendous physiologic abnormalities, co-morbid diseases and decreased cardio-respiratory reserve.[1,2]

We are reporting a female patient of age 120 years, weighing 50 kg, who presented to our institute for a possible surgery on fracture neck of femur. There is no literary evidence whereby anesthetic assessment and surgery has been carried out for a 120-year-old geriatric patient. Before this injury, she was able to move at her home and carried out daily chores herself. Apart from diminished hearing, there was no positive history of any systemic illness, prior hospitalization, surgery or allergy to any drug. The investigations and clinical examination revealed no abnormal findings. Pre-loading was done with 10 ml/kg of Ringer lactate solution. She was administered epidural anesthesia with 18-G Tuohy needle at L_4-5 interspace and was administered inj. ropivacaine 0.75% admixed with 45 μg of clonidine in aliquots of 5, 3 and 3 ml in a graded manner at an interval of 5–7 minutes. The intraoperative surgical and anesthetic course was uneventful, and the estimated blood loss was approximately 400–500 ml. The surgery lasted for 2 hours and she received one unit of blood intraoperatively. Postoperative period was uneventful and she was administered epidural top-ups with 6 ml of 0.25% ropivacaine for postoperative analgesia for the next 72 hours. The patient was discharged from the hospital after an uneventful stay.

The reduction in cardiovascular, pulmonary, renal and central nervous system functions in geriatric patients may be the most important determinants of outcome from surgical procedures under general or regional anesthesia.[3] The surgery was necessary as the patient was experiencing an excruciating pain on slight movement and there was a possibility of the patient being bedridden for the rest of her life. We preferred graded epidural technique as regional anesthesia produces less postoperative confusion and delirium as compared to general anesthesia, with a simultaneous control over the hemodynamic parameters.[4–6] Clonidine, as an adjuvant in epidural anesthesia, prolongs postoperative analgesia, helps in decreasing the volume of local anesthetic required to achieve the desired anesthetic effect and eliminates the opioid related side effects like respiratory depression, pruritis, nausea and vomiting.[7,8] It has been established that geriatric population shows an exaggerated response to the effects of opioid analgesia with a consequent decrease in opioid requirement through epidural route, mainly due to increase in cerebrospinal fluid levels.[9] Epidural top-ups with ropivacaine further obviate the need for any systemic analgesics or opioids and their related side effects, thus allowing early pain-free passive movements. A very careful titration of the anesthetic drugs has to be carried out while dealing with such patients. The patho-physiological aspects of hepatic, renal, cardiovascular, musculoskeletal, autonomic and central nervous system functions at this age have not been documented anywhere in the literature though there are numerous reports available for patients between 65 and 90 years. So, it is the responsibility of the seniormost anesthesiologist to let the entire surgical procedure to be carried out in his or her presence in order to prevent any untoward incident as these patients can be highly unpredictable as far as patho-physiological responses to surgical and anesthetic stress are concerned.