Fractional Spinal Anesthesia Improves Hemodynamic Stability in High-Risk Elderly Patients Undergoing Orthopedic Surgery: Case Series
A recent case series report shows that fractionating spinal anesthetic doses delivers superior hemodynamic stability over single-bolus injection in high-risk elderly orthopedic patients.
These findings of the case series report are published in the Indian Journal of Anaesthesia by Dr. Suvarna Kaniyil and colleagues at Government Medical College, Kozhikode.
The series evaluated five elderly individuals graded ASA physical status III–IV presenting with lower limb fractures and severe comorbidities. All patients underwent spinal block using hyperbaric bupivacaine 0.5% (7.5–10 mg) co-administered with fentanyl 20 µg.
Case 1: 75-Year-Old Female
A woman with hypertension, diabetes, Parkinsonism, and recent non-ST elevation myocardial infarction managed on dual antiplatelets presented with a femoral neck fracture. Preoperative testing showed renal dysfunction, anemia, and left ventricular hypertrophy with an ejection fraction of 50%. She underwent successful hemiarthroplasty under fractional spinal block (two-thirds baseline dose, one-third after 90 seconds) without cardiac complications.
Case 2: 90-Year-Old Male
A nonagenarian with a trochanteric fracture had a bioprosthetic aortic valve replacement, atrial fibrillation, grade 2 exertional dyspnoea, diastolic dysfunction, and pulmonary hypertension. Spinal medication was administered in three equal portions spaced 45 seconds apart. Mild hypotension at 10 minutes responded promptly to a single 50 µg phenylephrine bolus.
Case 3: 70-Year-Old Male
A hypertensive male (baseline blood pressure 200/120 mmHg) with rheumatic mitral stenosis (valve area 1 cm²), mitral regurgitation, and pulmonary hypertension presented with a femoral neck fracture. Following femoral nerve block, paracetamol, midazolam, and dexmedetomidine stabilization, fractional intrathecal injection (two-thirds initially, one-third at 90 seconds) was performed. Two 50 µg phenylephrine boluses managed transient hypotension at 5 minutes.
Case 4: 80-Year-Old Male
A hypertensive smoker with coronary artery disease, elevated troponin I, and a recent stroke causing left-sided hemiparesis presented with a femur fracture. Echocardiography revealed a patent foramen ovale with a left-to-right shunt and moderate ventricular dysfunction. Fractional spinal administration ensured smooth intraoperative management.
Case 5: 78-Year-Old Male
An asthmatic male with acute bronchospasm, baseline hypoxia (saturation 86%), aortic sclerosis, and pulmonary hypertension required femur fracture fixation. After bronchodilator nebulization and oxygen therapy, fractional spinal blockade provided complete anesthesia with a single 50 µg phenylephrine requirement at 10 minutes.
Mechanistic Insights
Conventional bolus spinal anesthesia induces abrupt sympathectomy, triggering severe hypotension that compromised geriatric patients cannot tolerate due to diminished cardiac reserve. Dosing fractionation restricts initial drug dispersion, causing gradual, limited vasodilatation. Subsequent fractional doses act upon previously blocked neural segments, extending block duration without worsening vasodilation.
Implications for Clinicians
Fractional spinal anesthesia offers a practical, hemodynamically conservative regional technique for elderly high-risk patients. By minimizing rapid sympathectomy, vasopressor requirements, and systemic fluctuations, this approach enables safe orthopedic surgical care in frail patients with severe cardiopulmonary disease.
Reference
Kaniyil S, Priya PG, Nithinkumar MP, Sneha SR. Fractional spinal anesthesia in high-risk elderly patients for orthopedic surgery—Case series. Indian J Anaesth. 2023;67(7):651-654.
