Management of a Case of Intertrochanteric Fracture in a 98 Years Old Patient

Abstract

A 98 years old male patient, diagnosed as intertrochanteric fracture femur, was posted for fixation by dynamic hip screw. His weight was 70 Kg, height 160 cm, blood pressure of 130/90 mm of Hg and a pulse of 56 per minute. He was conscious and oriented in time, place and person. There was no history of chest pain or dyspnoea. His investigations revealed haemoglobin, creatinine, TLC, DLC, with in normal range. Serum sodium 132 mEq/litre. His random blood sugar was 94 mg%. Chest x-ray was showing mild emphysematous changes. Electrocardiogram showed ST segment depression of 1 mm and T wave inversion in chest leads V 1& V2. Echocardiography was normal with LVEF 42%. In view of extreme old age and low ejection fraction, epidural anaesthesia was planned. Procedure was explained to the patient and he was kept nil by mouth for 8 hours. Patient was premedicated with inj. Metoclopramide 10 mg half an hour before surgery. Intravenous access was secured with 18G cannula and monitor was attached. ECG, blood pressure, SpO2, respiratory rate and temperature was monitored. Patient was placed in sitting position with legs hanging by the side of the operation table & supported on a footrest and 18G Tuohy needle was inserted by a paramedian approach into L4-L5 interspace using loss of resistance technique. Epidural catheter was introduced through needle up to 5 cm in cephalad direction. 3 Test dose of 2 ml of lidocaine with adrenaline was given, after that drug solution 8 ml lidocaine 2% +6ml of 0.5% Bupivacaine + 50 mg Tramadol) was slowly injected through catheter after negative aspiration. T8 sensory level was achieved and procedure lasted for one and half hour. Intravascular volumes were maintained by giving Ringer lactate and normal saline solutions. Patient remained hemodynamically stable throughout the procedure except two initial episodes of hypotension which were managed by inj. Mephentermine 3 mg. There was no significant blood loss during the surgery. 4 No untoward complication occurred throughout the course of operation. Patient was shifted to intensive therapy unit for postoperative care. Eight hourly supplementations of Inj. Tramadol 100 mg was done through epidural catheter for 3 days for postoperative analgesia. Patient did well postoperatively and was discharged from hospital after one week.