Titrated segmental epidural anesthesia for bilateral total knee replacement in a patient with severe aortic stenosis and severe bilateral carotid artery stenosis: a case report

Abstract

Background Total knee replacement is a major orthopedic procedure for severe, painful, and mobility-limiting knee arthritis. Aortic valve stenosis is the most frequent valvular heart disease and the most commonly performed valvular procedure. Stenosis of the valve may lead to left ventricular hypertrophy, ventricular dysfunction, myocardial ischemia, and a state of fixed cardiac output. Changes in hemodynamic parameters such as hypotension and bradycardia in patients with carotid artery stenosis may lead to cerebrovascular accidents, especially during anesthesia. Case presentation A 76-year-old woman with a 6-year history of bilateral knee pain. The pain was dull, aching, and severe in intensity, and it prevented her from sleeping despite optimal analgesics. A general physical examination revealed an elderly, frail woman in mild respiratory distress. She had bilateral small-volume radial pulses, positive hepatojugular reflux, and heart sounds of S1, S2, and S4 with an ejection systolic murmur, and carotid bruits were heard bilaterally. Epidural anesthesia was done by injection of 2.5 mL of 0.5% plain bupivacaine in aliquots every 5 min until the level of the block reached the suprapubic region (titrated segmental epidural anesthesia). The patient was not preloaded with intravenous fluid prior to the establishment of epidural anesthesia, and the epidural anesthesia-induced hypotension that may ensue was managed with intraoperative dopamine infusion at 5 µg/kg/min. Conclusions Titrated segmental epidural anesthesia with intraoperative infusion of low-dose dopamine reduces the perioperative risk of myocardial infarction, cerebrovascular accident, and neurocognitive deficit in a patient with severe aortic stenosis and severe bilateral carotid stenosis.