Document resource
Background and Aims 76-years old patient with severe aortic stenosis and pharyngeal carcinoma with ongoing neck radiotherapy was scheduled for hip arthroplasty due to fractured femoral neck. Intubation was high-risk due to radiotherapy and spinal anesthesia was high-risk due to aortic stenosis. We chose combination of unilateral neuraxial anesthesia with analgetic regional blockade combining pericapsular nerve group (PENG) and lateral femoral cutaneous nerve (LFCN) block under the ultrasound guidance.Methods Blood pressure was monitored invasively with arterial cannula placed in right radial artery. Prior to spinal anesthesia patient received a 500 ml bolus of normal saline over 30 minutes following PENG and LFCN analgetic blockade using 20 ml and 5 ml of 0.5% levobupivacaine, respectively. Unilateral neuraxial anesthesia was performed in left lateral decubitus position with 1 ml of hypobaric aqua and 1 ml of 0.5% levobupivacaine (5 mg), using atraumatic Whitacre needle (27G).Results Following neuraxial anesthesia, we observed no hypotensive episodes in the first half an hour. Afterwards, we maintained blood pressure drops within 20% from baseline (150/90 mmHg) with norepinephrine and phenylephrine boluses (2.5 mcg and 100 mcg, respectively). The biggest hypotensive episode was observed after cementing of the prosthesis (90/50 mmHg) when we initiated norepinephrine infusion in minimal doses (0.03 mcg/kg/min) until the end of surgery. Following surgery patient was transferred to ICU for a 24-hour monitoring. He arrived at ICU with normal blood pressure with no additional drops, received no additional analgesia and was transferred to ward the next morning.Conclusions Severe aortic stenosis is not an absolute contraindication for neuraxial anesthesia, especially in cases of unilateral block with low-dose anesthetic concentration supplemented with regional analgetic blockade. Hypotensive episodes should be addressed with vasoconstrictive medication due to peripheral vasodilatation following neuraxial anesthesia while avoiding tachycardia and with administration of normal saline boluses prior to anesthesia.