Case week 1 (w/c 03/10/11)
You are responsible for the trauma list. You are asked to anaesthetise a 75 year old lady with a fractured neck of femur for a hemi arthroplasty. What is your default technique for this?
Keep your answers brief initially. More information regarding the case will be available once we have had some replies & remember the aim is to educate trainee anaesthetists.
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Additional case details
You make a preoperative visit to the patient. She is obese. 125kg, 5ft tall, large belly. Smoker. COPD. SpO2 93% on air.
‘Doesn’t get out of the house much’ Can potter around the bungalow with a frame.
She has poor eye sight and Osteoarthritis. Has an electric bed and doesn’t like lying flat. Often sleeps in a chair during the day.
Will any of the above change your plan? Explain with provisos if necessary..
Summary of comments
Fractured neck of femur (proximal femoral fracure) is often regrded as a frailty fracture.
It carries a significant 30 day and 1 year mortality.
By definition the patients are often frail with multiple co morbidity which needs to be taken into account when planning anaesthesia.
There is no hard evidence supporting general anaesthesia over regional anaesthesia and the decision must be made on an individual basis.
What evidence there is suggests that regional anaesthesia results in less postoperative cognitive dysfunction which can be problematic in this group of patients.
Patient care is improved with a fast track route from A&E to a ward.
It is important patients recieve surgery promptly (within 36 hours) by an experienced anaethetist and surgeon.
In our specific case, more people were in favor of general anaesthesia due to it’s ‘titratability’.
Most opted for an endotracheal tube and positive pressure ventilation in view of the obesity.
There was some suggestion that spinal anaesthesia might be of benefit if the shortness of breath was respiratory in origin.
Many people opted for invasive arterial monitoring due to concern over cardiac function. They mentioned preoperative echo if available but not delaying surgery.
Several comments were made regarding the use of cardiac output monitoring to provide a more scientific method of fluid administation in the presence of possible cardiac failure.
Detailed guidance is soon to be available from the AAGBI (Draft is available here)