How should I induce and maintain anesthesia in a 62-year-old man with severe non‑ischemic cardiomyopathy (ejection fraction ~10%) undergoing open reduction and internal fixation of a femur fracture?

Anesthetic Management for ORIF in Severe Cardiomyopathy (EF 10%)

Critical Pre-Induction Preparation

In a 62-year-old man with an ejection fraction of 10% undergoing femoral ORIF, you must establish invasive arterial blood pressure monitoring before induction, ensure adequate pre-induction hydration, have vasopressors drawn up and immediately available, and plan for advanced hemodynamic monitoring throughout the case 1, 2.

Mandatory Monitoring & Access

• Place an arterial line in the radial artery before induction; invasive blood pressure monitoring is specifically indicated for patients with limited left ventricular function undergoing orthopedic procedures 1, 2.
• Strongly consider pulmonary artery catheter placement for continuous cardiac output monitoring and mixed venous oxygen saturation (SvO₂) in patients with EF <20% 3, 4.
• Central venous access is recommended for patients with severely limited left ventricular function to guide fluid therapy and provide reliable vasopressor delivery 1, 4.
• Prepare phenylephrine (100–200 µg boluses) or metaraminol before induction and keep immediately available at the head of the bed 1, 2.

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Induction Strategy

Use etomidate 0.15–0.2 mg/kg for induction because it provides the most hemodynamic stability in patients with severe ventricular dysfunction 5, 4.

Induction Agent Selection & Dosing

• Etomidate is the preferred induction agent for patients with dilated cardiomyopathy and severe systolic dysfunction because it maintains cardiac output and systemic vascular resistance better than propofol or thiopental 5, 4.
• Reduce the etomidate dose by 20–25% (to approximately 0.15 mg/kg) to account for age-related pharmacokinetic changes in a 62-year-old patient 2, 5.
• Avoid propofol for induction in this patient; propofol causes significant myocardial depression and vasodilation that can precipitate cardiovascular collapse in patients with EF <15% 5, 4.
• Ketamine should not be used for induction despite its reputation for cardiovascular stability, because it increases myocardial oxygen demand and carries significant risk of postoperative confusion in patients over 60 years 2, 6.
• Avoid all benzodiazepines (including midazolam for anxiolysis) because they are strongly associated with postoperative delirium in elderly patients and provide no hemodynamic benefit 2, 6.

Muscle Relaxation

• Administer rocuronium 0.9–1.2 mg/kg for rapid sequence intubation if aspiration risk is present, or 0.6 mg/kg for standard intubation 1.
• Avoid succinylcholine in this patient population due to the risk of hyperkalemia and arrhythmias in the setting of severe cardiomyopathy 4.

Hemodynamic Goals During Induction

• Maintain systolic blood pressure within ±20% of pre-induction baseline using vasopressors rather than fluid boluses 1, 2, 7.
• Target mean arterial pressure >65 mmHg throughout induction and maintenance; hypotension below this threshold is associated with increased mortality 2.
• Administer phenylephrine or metaraminol immediately if systolic BP drops >20%; do not wait to give additional IV fluids first 1, 2.
• Ensure adequate pre-induction hydration with 250–500 mL of balanced crystalloid to reduce the likelihood of induction-related hypotension 1, 2.

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Maintenance of Anesthesia

Maintain anesthesia with a volatile anesthetic (sevoflurane or isoflurane at 0.5–1.0 MAC) combined with low-dose fentanyl or remifentanil infusion, avoiding high concentrations of volatile agents that depress myocardial contractility 5, 4.

Volatile Anesthetic Selection & Dosing

• Sevoflurane 0.5–1.0 MAC is preferred because it causes less myocardial depression than higher concentrations and maintains better hemodynamic stability in patients with severe systolic dysfunction 5, 4.
• Isoflurane 0.5–1.0 MAC is an acceptable alternative with similar hemodynamic profile to sevoflurane at low concentrations 5.
• Do not exceed 1.0 MAC of volatile anesthetic in this patient; higher concentrations cause dose-dependent myocardial depression and vasodilation that can precipitate cardiovascular collapse 5, 4.
• Consider depth-of-anesthesia monitoring (BIS) to optimize anesthetic depth and avoid excessive myocardial depression, particularly in patients over 60 years at risk of hypotension 1.

Opioid Strategy

• Use fentanyl 2–5 µg/kg total intraoperatively or a remifentanil infusion 0.05–0.1 µg/kg/min to provide analgesia while minimizing hemodynamic depression 5, 4.
• Reduce opioid doses by 20–25% to account for age-related pharmacodynamic changes in a 62-year-old patient 2, 5.
• Avoid large boluses of fentanyl (>100 µg) because they can cause bradycardia and hypotension in patients with limited cardiac reserve 4.

Ventilation Strategy

• Use low tidal volumes (6–8 mL/kg predicted body weight) with PEEP ≥5 cm H₂O to minimize adverse hemodynamic effects of positive-pressure ventilation 1.
• Avoid excessive PEEP (>10 cm H₂O) because it reduces venous return and can precipitate hypotension in patients with severe systolic dysfunction 4.

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Intraoperative Hemodynamic Management

Maintain systolic blood pressure within ±20% of baseline using vasopressors as first-line therapy, not fluid boluses, and communicate with the surgeon before femoral canal instrumentation to anticipate potential cardiovascular instability 1, 2, 7.

Vasopressor & Inotrope Strategy

• Phenylephrine 100–200 µg boluses are first-line for hypotension when heart rate is adequate (>60 bpm) 1, 2.
• Ephedrine 5–10 mg boluses are preferred if bradycardia (<60 bpm) accompanies hypotension because it provides both chronotropic and vasopressor effects 4.
• Have an epinephrine infusion prepared (0.01–0.05 µg/kg/min) for refractory hypotension or cardiovascular collapse; epinephrine provides both inotropic and vasopressor support 1, 3, 4.
• Consider a low-dose dobutamine infusion (2–5 µg/kg/min) if cardiac output monitoring reveals low cardiac index despite adequate preload 3, 4.

Fluid Management

• Use balanced crystalloids (Ringer's lactate or Plasma-Lyte) rather than 0.9% saline for all intravenous fluid administration 1.
• Avoid excessive fluid administration; only approximately 54% of hypotensive patients respond to fluid boluses, and volume overload worsens outcomes in patients with severe systolic dysfunction 2, 4.
• Administer fluid boluses (250 mL) only if a passive leg raise test demonstrates preload responsiveness (increase in blood pressure with PLR) 2.

Critical Surgical Phases

• Maintain heightened vigilance during femoral canal reaming and nail insertion because these steps can precipitate fat embolism, hypotension, and cardiovascular collapse 1, 2, 7.
• Confirm with the surgeon immediately before femoral canal instrumentation to prepare for potential hemodynamic events 1, 2, 7.
• Have vasopressors and epinephrine immediately available during femoral instrumentation because adverse cardiovascular events occur in approximately 20% of cases involving femoral canal manipulation 1, 7.

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Regional Anesthesia Considerations

Do not perform spinal or epidural anesthesia as the primary anesthetic in this patient; the sympathectomy-induced vasodilation and hypotension are poorly tolerated in patients with EF 10% 2, 4.

Peripheral Nerve Block for Analgesia

• Consider a femoral nerve block or fascia iliaca block with 20–25 mL of 0.25% bupivacaine under ultrasound guidance for postoperative analgesia, performed after induction and hemodynamic stabilization 2.
• Peripheral nerve blockade reduces postoperative opioid requirements and lowers the risk of postoperative confusion without causing the hemodynamic instability associated with neuraxial techniques 2.
• Ultrasound guidance is mandatory to minimize required volume and reduce the risk of vascular puncture 2.

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Postoperative Management

Plan for 24–48 hours of intensive care monitoring with continuous arterial pressure monitoring, cardiac output assessment, and multimodal analgesia using peripheral nerve blocks and reduced-dose opioids 2, 7, 3.

Monitoring & Disposition

• Transfer the patient to the ICU with continuous arterial line monitoring for at least 24–48 hours postoperatively 7, 3.
• Continue cardiac output monitoring (PA catheter or minimally invasive CO monitor) to guide fluid and inotrope management 3, 4.
• Monitor for delayed complications including fat embolism syndrome, myocardial ischemia, and arrhythmias 7.

Analgesia Strategy

• Administer paracetamol 1000 mg every 6 hours as baseline analgesia 2.
• Use the femoral nerve block to provide 12–18 hours of postoperative analgesia and reduce opioid requirements 2.
• Reduce rescue opioid doses by 20–25% (e.g., morphine 2–3 mg IV every 4 hours as needed) to account for age-related pharmacokinetic changes 2.
• Avoid NSAIDs in this patient given the high likelihood of renal dysfunction and the risk of fluid retention in severe heart failure 1, 2.
• Avoid codeine and tramadol because they are associated with postoperative cognitive dysfunction in elderly patients 1, 2.

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Critical Pitfalls to Avoid

• Never use propofol for induction in patients with EF <15%; the myocardial depression and vasodilation can cause irreversible cardiovascular collapse 5, 4.
• Never perform spinal or general anesthesia simultaneously; combining techniques causes precipitous hypotension 2.
• Never rely on fluid boluses alone to treat hypotension; use vasopressors first-line to avoid volume overload 2, 4.
• Never use ketamine for induction or sedation in elderly patients due to the significant risk of postoperative confusion 2, 6.
• Never administer benzodiazepines at any point in the perioperative period; they are strongly associated with postoperative delirium 2, 6.
• Never exceed 1.0 MAC of volatile anesthetic; higher concentrations cause unacceptable myocardial depression in patients with severe systolic dysfunction 5, 4.