Regional Anesthesia in Patients of Aged 99 Years in Clopidogrel Use.

The risk of neuraxial block in patients treated with antiplatelet drugs are uncertain. Elderly patients often have low physiological reserve, delaying surgery can lead to a high rate of morbidity and mortality. The aim of this paper is to present a case of a patient with 99 years using clopidogrel undergoing regional anesthesia for surgical treatment of hip fracture without complications.

INTRODUCTION

The risk of neuraxial blockade in patients treated with the new antiplatelet drugs is uncertain, due to lack of available data regarding the safety lock, associated with a large difference of opinion not only among anesthesiologists but also among the published guidelines in together with the perception of an increased risk of bleeding by a powerful effect on platelet function, it led to reluctance to recommend its continuation in the perioperative period.[12] Elderly patients usually have reduced physiological reserve, which can lead to postoperative complications,[3] delaying surgery in this group can lead to high mortality and morbidity where survival is higher in patients who have their operation performed on the day of admission, particularly in elderly >80 years.[4]

The objective of this report is to present a case of a patient with 99 years old being treated with clopidogrel submitted to regional anesthesia for surgical treatment of transtrochanteric hip fracture.

CASE REPORT

A 99-year-old female patient, 68 kg, physical status American Society of Anesthesiologists (ASA) III, Goldman cardiac risk Class II, holder of obstructive coronary artery disease treated with bisulfate clopidogrel (75 mg) for 9 years, aortic insufficiency, and bradyarrhythmia was presented.

She was admitted for surgical treatment of the fracture in the right femur due to falling from height. She had coagulation (international normalized ratio 1.18) and platelet function unchanged (167,000/mm3). After a brief meeting between anesthesiologist, orthopedic surgeon, and cardiologist, she is opted for surgery as soon as possible.

In the operating theater, she made with cardioscope monitoring, pulse oximetry, and noninvasive blood pressure. The patient was held venoclysis with an 18-gauge catheter, infusion solution ringer lactate, and hydroxyethyl starch 6%, cefazolin (2 g), and dexamethasone (10 mg); she had midazolam (0.5 mg) as premedication.

Performed lumbar plexus block through inguinal with continuous plexus block set (Contiplex® D18, B. Braun Melsungen, Germany) connected to the neurostimulator device (Stimuplex HNS 12, B. Braun Melsungen, Germany), infusion of 2% lidocaine with epinephrine (20 ml) and levobupivacaine hydrochloride of 50% enantiomeric excess (20 ml) with subsequent passage of the catheter. After 30 min, performed spinal anesthesia level L3-L4 with Quincke needle 27-gauge, single puncture, infusion isobaric bupivacaine 0.5% (10 mg), Bromage scale 3.

The surgical procedure lasted for 60 min, was installed elastomeric pump hydrochloride levobupivacaine enantiomeric excess of 50%. 0.1% (400 ml), parecoxib sodium (40 mg), and dipyrone (4 g), and then sent to the ward. It was evaluated in the 1st, 2nd, 7th, and 15th day after surgery with a satisfactory outcome.

DISCUSSION

Bleeding is the major complication of the use of anticoagulant drugs and thrombolytic therapy.[5] Risk factors for severe bleeding during anticoagulation include the intensity of anticoagulation, advanced age, female gender, history of gastrointestinal bleeding, aspirin use, and duration of therapy.[67]

Guidelines have been published by international companies in order to increase security in relation to neuraxial blocks in patients on anticoagulants.[89101112]

Spinal hematoma is a rare event which occurs more frequently than spontaneously as a result of neuraxial anesthesia.[13] Bleeding into the spinal canal causing compression of the thecal sac often results in irreversible neurological damage, such as paraplegia. The clinical manifestation is characterized by slow or absent regression of motor block or sensitive, back pain, urinary retention or return of motor or sensory deficit after full preview of blockade regression, separately or in combination, suggesting the development of spinal hematoma.[14] Being a neurosurgical emergency and confirmed the diagnosis, decompressive laminectomy should be performed within 6–12 h after the onset of symptoms, enabling chances of complete neurological recovery.[1516]

The antiplatelet drugs consist of nonsteroidal anti-inflammatory drugs, thienopyridines (ticlopidine, clopidogrel, and prasugrel) and glycoprotein IIb/IIIa. Clopidogrel is a platelet inhibitor belonging to the class of thienopyridines. Prodrugs are cleaved in vivo in the liver to active metabolites that antagonize the platelet receptor adenosine dinucleotide phosphate (P2Y12) and interfere with platelet activation and aggregation, an effect that cannot be antagonized, and is irreversible. It has a half-life of elimination of 120 h; however, its active metabolite is only 8 h.[114] The recovery of platelet function occurs 6–7 days after the end of administration.[17]

Despite reports of spinal hematoma after neuraxial anesthesia, there are no prospective studies evaluating the safety of neuraxial techniques in the presence of treatment with clopidogrel.[18]

Patients’ undergoing orthopedic surgery has a high incidence of thromboembolic complications. The elderly usually have physiological reserve and diminished hemodynamic conditions, where attention should be paid to perioperative complications. The delay in surgery in these patients can be disastrous, with very high risk of morbidity and mortality.

The physical status of the ASA, classified as ASA III patients with severe systemic changes with functional limitations, with perioperative mortality rate of 7.8–25.9%.[19]

The cardiac risk index described by Goldman et al., in 1977, the first specific multifactorial model for perioperative cardiac complications widely used. This index includes variables related to clinical evaluation, electrocardiogram, and type of surgery, giving scores to stratify patients in Classes I to IV on the risk for cardiovascular complications or lead to death.[20]

The case report shows that regional anesthesia in this patient with 99 years on clopidogrel, with coagulation, and platelet function unchanged was safe, leaving to delay surgery, and avoiding increased morbidity and mortality, with the patient returning their daily activities within the expected term.

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Conflicts of interest

There are no conflicts of interest.