Background: Severe aortic stenosis is a serious condition which requires tight haemodynamic control during surgery. We present an example of its management using an uncommon anaesthestic technique: continuous spinal anaesthesia.

Case Report: An 83-year-old man presented at the Emergency Department due to an accidental fall. Radiographic evaluation showed a total hip arthroplasty periprosthetic fracture. Past medical history included severe aortic stenosis, Parkinson disease with dementia, and COPD. Due to patient comorbities we decided to perform the procedure under peripheral nerve blocks and continuous spinal anaesthesia. Ultrasound-guided femoral and lateral cutaneous femoral blocks were done with 20ml of ropivacaine 0.5%. Dural puncture at L3-L4 level followed, using a 18G Tuohy needle, and the catheter introduced intrathecally. 1mcg of sufentanyl and 3mg of isobaric bupivacaine were given through the catheter, and pushed forward with 1.2ml bupivacaine. Surgical sensitive blockade was accomplished 15 minutes later. The procedure lasted 2 hours without any further anaesthetic administration. No adverse haemodynamic effects or cardiac events were noted and postoperative recovery was uneventful. The patient did not complain of postdural puncture headache or lower limb pain after surgery, and was safely discharged from anesthesia care.

Discussion: Continuous spinal anesthesia is a rarely-used technique for providing effective anesthesia. The anaesthetic management of patients with severe aortic stenosis requires careful planning to minimize the already known high morbidity and mortality secondary to preload and afterload sudden decreases. These patients depend on adequate preload to overcome the mechanical outflow obstruction, but also on afterload which ensures coronary perfusion (of particular importance considering the oxygen requirements of a typically hypertrophied heart). Finally, reflex tachycardia from a single-shot spinal can cause sudden hemodynamic collapse.

Learning points: Continuous spinal anaesthesia, although uncommon, remains a useful anaesthetic skill. An aging population and its increasing effects on health issues, namely severe cardiovascular disease, challenges anesthesiologists to provide effective and safe intra-operative care.

06 / Continuous spinal anaesthesia in the high-risk orthopedic elderly patient: a case report.