From the Guidelines
For an 89-year-old female with a neck of femur fracture and newly discovered asymptomatic severe left ventricular dysfunction (EF 25%), I recommend proceeding with spinal anesthesia rather than general anesthesia. This approach is supported by the Scottish Intercollegiate Guidelines Network, which suggests that spinal or epidural anesthesia should be considered for all patients undergoing hip fracture repair, unless contraindicated 1. The use of regional anesthesia, such as spinal anesthesia, may reduce the incidence of postoperative confusion and is considered the technique of choice, although the limited evidence available does not permit a definitive conclusion to be drawn with regard to mortality or other outcomes 1.
When performing spinal anesthesia, it is essential to use a reduced dose of hyperbaric bupivacaine (7.5-10mg) with careful titration to achieve adequate surgical block while minimizing hemodynamic effects. Prior to anesthesia, it is crucial to optimize her cardiac status with a cardiology consultation and consider starting a low-dose beta-blocker (such as metoprolol 12.5mg twice daily) if not contraindicated. Ensuring adequate preload with judicious fluid management, targeting euvolemia with crystalloids (balanced solutions like Hartmann's/Ringer's lactate), is also vital. Maintaining hemodynamic stability with small boluses of vasopressors as needed (phenylephrine 50-100mcg or ephedrine 3-6mg) and implementing continuous invasive arterial pressure monitoring can help minimize the risks associated with anesthesia in a patient with severe cardiac dysfunction.
Additionally, considering peripheral nerve blockade as an adjunct to spinal anesthesia can extend the period of postoperative non-opioid analgesia, reducing the need for opioid analgesics and minimizing the risk of respiratory depression and postoperative confusion 1. Postoperatively, transferring the patient to a high-dependency unit for 24-48 hours of close monitoring can help ensure the best possible outcome. This approach balances the urgency of hip fracture repair (ideally within 48 hours) with the risks of anesthesia in a patient with severe cardiac dysfunction, minimizing myocardial depression while providing adequate anesthesia for surgery.
From the Research
Patient Assessment
The patient is an 89-year-old female with a non-surgical (NOF) fracture and an ejection fraction (EF) of 25%, but is asymptomatic of heart failure.
Anaesthesia Considerations
When considering anaesthesia for this patient, the following factors should be taken into account:
- The patient's reduced ejection fraction (EF of 25%) indicates heart failure with reduced ejection fraction (HFrEF) 2, 3.
- The patient is asymptomatic of heart failure, which may affect the choice of anaesthesia and perioperative management.
- The presence of a NOF fracture may require surgical intervention, which should be done with caution given the patient's cardiac status.
Management of Heart Failure
The management of HFrEF typically involves a combination of medications, including:
- Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor-neprilysin inhibitors (ARNI) 3.
- Beta-blockers, which may improve ejection fraction and reduce mortality 2, 3.
- Mineralocorticoid receptor antagonists (MRA), which may reduce heart failure hospitalization 4.
- SGLT2 inhibitors, which may improve outcomes in patients with HFrEF 3.
Perioperative Management
The perioperative management of patients with HFrEF should focus on:
- Optimizing cardiac function and volume status before surgery.
- Avoiding medications that may worsen heart failure, such as non-steroidal anti-inflammatory drugs (NSAIDs).
- Using anaesthetic techniques that minimize cardiac stress and maintain stable haemodynamics.
- Monitoring cardiac function and volume status closely during and after surgery.
Anaesthetic Options
The choice of anaesthesia will depend on the patient's overall health status, the type of surgery, and the anaesthesiologist's preference. Options may include:
- General anaesthesia with careful monitoring of cardiac function and haemodynamics.
- Regional anaesthesia, such as spinal or epidural anaesthesia, which may reduce cardiac stress and improve outcomes.
- Sedation and analgesia, which may be used for minor procedures or in patients who are at high risk for general anaesthesia.
It is essential to consult with a cardiologist and an anaesthesiologist to determine the best approach for this patient's anaesthesia and perioperative management, considering her specific condition and the latest evidence-based guidelines 2, 3, 4.