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Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 152-154  

Sequential combined spinal-epidural anesthesia in a multiple comorbidity patient: An indispensable tool in anesthesiologists' armamentarium

Department of Anesthesiology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India

Date of Submission12-May-2021
Date of Acceptance10-Jun-2021
Date of Web Publication30-Aug-2021

Correspondence Address:
Dr. Ashita Mowar
Department of Anesthesiology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly - 243 202, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aer.aer_68_21

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Primary total knee joint arthroplasty (TKA) is a frequently performed procedure as part of osteoarthritis treatment. Optimal perioperative analgesia will augment functional recovery, improve knee mobility, and reduce postoperative morbidity. Octa- and nonagenarians undergoing TKA are often considered particularly difficult to manage and involve high levels of competence due to associated comorbidities these patients present with. We report a case of a geriatric patient with coronary artery disease and low ejection fraction with pulmonary fibrosis who underwent successful total knee arthroplasty under sequential combined spinal-epidural anesthesia.

Keywords: Ejection fraction, postoperative analgesia, pulmonary fibrosis, sequential spinal epidural

How to cite this article:
Singh V, Mowar A, Pahade A, Karki G. Sequential combined spinal-epidural anesthesia in a multiple comorbidity patient: An indispensable tool in anesthesiologists' armamentarium. Anesth Essays Res 2021;15:152-4

How to cite this URL:
Singh V, Mowar A, Pahade A, Karki G. Sequential combined spinal-epidural anesthesia in a multiple comorbidity patient: An indispensable tool in anesthesiologists' armamentarium. Anesth Essays Res [serial online] 2021 [cited 2022 Aug 9];15:152-4. Available from:

   Introduction Top

With gradual improvement in health-care systems, life expectancy has increased across the world. This has resulted in a spike in geriatric patients going under the knife for a host of degenerative diseases. Current-day anesthesiologists are more likely to administer anesthesia to octa- and nonagenarians in coming future, which shall involve high levels of competence due to associated comorbidities these patients present with.

Osteoarthritis is one such degenerative disease which commonly affects elderly age group. Primary total knee joint arthroplasty (TKA) is a frequently performed procedure as part of osteoarthritis treatment. In the United States of America alone, a 110% rise in TKA is being projected by 2025.[1]

While intraoperative management being a challenging scenario, postoperative pain following orthopedic surgery is often considered particularly difficult to manage, with up to half of the patients reporting significant pain following surgery. This may have a detrimental impact on postoperative recovery due to delay in ambulation, thereby increasing the length of hospital stay.[2]

We hereby report successful perioperative anesthetic management of an elderly patient suffering from critical coronary artery disease with significantly hampered cardiac function and pulmonary fibrosis who underwent total knee arthroplasty under central neuraxial blockade.

   Case Report Top

A 78-year-old male suffering from generalized osteoarthritic changes was scheduled for TKR. A known hypertensive for the past 2 years was on irregular treatment. Upon eliciting a detailed history, the patient had experienced dyspnea and chest pain upon moderate exertion, following which coronary angiography (CAG) was performed to rule out underlying ischemic heart disease. CAG was suggestive of critical triple-vessel disease, and the patient was advised surgical revascularization. However, our patient opted for conservative medical management then and was asymptomatic ever since.

While electrocardiography (EKG) was unremarkable, preoperative echocardiography revealed reduced global wall motion with left ventricular ejection fraction of 20% and elevated right ventricular systolic pressure suggestive of moderate pulmonary artery hypertension. Preoperatively, the patient had an oxygen saturation SpO2 of 87% on room air which improved to 92% on 2 at 4 L/min. General and systemic examination revealed no abnormality. Airway examination was normal.

Routine preoperative blood investigations performed as per institutional protocol showed no abnormality. Chest X-ray showed bilateral coarse reticular shadows (honeycombing) suggestive of pulmonary fibrosis which was confirmed on high-resolution computed tomography scan. Pulmonary function test was suggestive of restrictive lung disease. Despite elaborate history being elicited from the patient and family members, the cause of pulmonary fibrosis could not be ascertained.

The patient was considered at high risk for perioperative anesthetic management, which was explained to the surgical team as well as the patient relatives, and consent was obtained for the same.

In view of anticipated perioperative challenges, a low-dose unilateral subarachnoid block with continuous epidural analgesic technique was planned. The patient was wheeled into the operating room, and all standard monitors were applied. Additional central venous and invasive arterial pressure monitoring was instituted prior to administering block.

Under all aseptic precautions, epidural catheter was inserted at L2–L3 intervertebral space with 18G Tuohy's needle with loss of resistance technique to air with unilateral subarachnoid block administered at L3–L4 intervertebral space with 27G Quincke's needle. A T10 block level was achieved with injecting 1.2 mL of 0.5% hyperbaric bupivacaine and block level advanced with titrated doses of 0.25% isobaric bupivacaine. The total duration of surgery was 1 h 30 min and tourniquet time was 60 min.

Intraoperative hemodynamics were maintained throughout and no features of coronary ischemia were present clinically on EKG monitoring. There was no requirement of any inotropic support during intraoperative or postoperative period. The patient was shifted to postanesthesia care unit following surgery. Postoperative analgesia was maintained with 0.1% isobaric bupivacaine infusion with satisfactory visual analogue scale (VAS) scores over the next 2 days.

   Discussion Top

The primary perioperative objective in patients with ischemic heart disease is to prevent perioperative myocardial ischemia by maintaining equilibrium between oxygen delivery and consumption, and treating accordingly if such an imbalance should occur, irrespective of the type of anesthetic technique employed or drug used.[3]

Regional anesthesia used alone or in combination with general anesthesia has the benefit of reducing preload and afterload which can improve cardiac output. However, chances of intraoperative hypotension must be alleviated to avoid any deleterious effects on myocardial perfusion.[4] A methodically balanced regional anesthetic technique provides an alternative for respiratory cripples undergoing major surgeries. As was the case in our patient who had comorbidities involving cardiopulmonary system making him a candidate at high risk for general anesthesia, central neuraxial blockade was considered the anesthetic of choice following careful assessment of the risk/benefit ratio.

Low-dose spinal anesthesia with placement of epidural catheter ensured avoidance of high intrathecal drug dosage needed for maintaining the level of block intraoperatively when the block began receding. While subarachnoid hyperbaric bupivacaine achieved an early block onset, aliquots of analgesic doses of isobaric bupivacaine through epidural catheter gave us liberty to achieve and maintain the desired level of block and hence satisfy patients' surgical needs, without compromising hemodynamic and respiratory parameters.[5]

Peripheral nerve blocks such as femoral nerve catheter block, adductor canal block, and the local anesthetic infiltration between the popliteal artery and capsule of the knee block are the recent modality of anesthesia following TKR, however, administering large drug volume for adequate block depth carries the risk of local anesthetic toxicity. Likewise, these techniques have been reported to cause quadriceps paresis, intravascular injection, hematoma, nerve injury/foot drop also rarely.[6]

The joint statement of the European society of cardiologists and anesthesiologists published in 2014 recommended that neuraxial anesthesia alone can be considered as the anesthetic technique of choice in patients with heart disease following risk/benefit ratio assessment for each patient. Neuraxial analgesia techniques result in improved postoperative outcome and should hence be considered as the technique of the first choice. While there are reports of patients with heart failure undergoing surgery under graded epidural anesthesia, there is insufficient literature supporting spinal anesthesia, therefore, making our less traveled technique unique and up for grabs and further research.[7]

   Conclusion Top

Hence, we recommend sequential combined spinal-epidural technique following careful risk assessment of risk/benefit ratio for each patient should be part of armamentarium of each of us, as this may be an answer to anesthesia for orthopedic surgeries of the lower limb in such patients with successful outcomes.[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Rheumatology advisor. Increased rate of total joint replacements predicted from 2020 to 2040. Rheumatology Advisor; 2019. Available from: hhtp:// [Last accessed on 2021 Jan 31].  Back to cited text no. 1
O'Donnell R, Dolan J. Anaesthesia and analgesia for knee joint arthroplasty. BJA Educ 2018;18:8-15.  Back to cited text no. 2
Shaheen MS, Sardar K, Chowdhury AK, Rahman MM, Alam MN, Ahmed R, et al. Ejection fraction <35% - Anaesthetic experience of 236 cases: A retrospective study. AKMMC J 2018;9:114-20.  Back to cited text no. 3
Vishwanath R Hiremath. Anaesthetic Management of the patient with low ejection fraction. Int J Basic and Applied Med Sci [Internet] 2013;4:8-11.  Back to cited text no. 4
Saxena K N, Saha M, Mishra D, Wadhwa B. Combined spinal epidural for total knee replacement in patients with low ejection fraction: A case series. J Anesthetic Res and Pain Med [Internet] 2019;4:1-5.  Back to cited text no. 5
Jain K, Jaiswal V, Puri A. Anesthesia for total knee replacement surgery in a patient with positive stress test. J Anaesthesiol Clin Pharmacol 2019;35:279-81.  Back to cited text no. 6
[PUBMED]  [Full text]  
Longrois D, Hoeft A, De Hert S. 2014 European Society of Cardiology/European Society of Anaesthesiology guidelines on non-cardiac surgery: Cardiovascular assessment and management: A short explanatory statement from the European Society of Anaesthesiology members who participated in the European Task Force. Eur J Anaesthesiol 2014;31:513-6.  Back to cited text no. 7


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