Background and Aims Aortic stenosis (AS) requires tight haemodynamic control during surgery. Sudden decreased in systemic vascular resistances could be fatal, therefore, neuraxial anaesthesia (NA) is traditionally contraindicated. However, evidence about this subject is sparse and the alternative of general anaesthesia (GA) may pose some troubles, especially in elderly patients with comorbidities.
Methods Female, 89-years, ASA IV, with hypertension, atrial fibrillation, severe AS and COPD, was admitted for hip fracture repair. We decided to perform a continuous spinal anaesthesia (CSA). Under standard ASA and invasive blood pressure monitoring, a 18G Tuohy needle was inserted, at L3-L4, into subarachnoid space and through it a 20G catheter was introduced 3cm into the space. After aspiration of cerebrospinal fluid, 5 mg of bupivacaine was administered in two divided doses with a 10-minute interval.
Results An adequate anaesthesia level at T10 was guaranteed throughout intraoperative. Hemodynamic parameters remained stable, with median arterial pressure superior to 80% of baseline, without vasopressor use. No additional bupivacaine was needed. Spinal catheter was removed before discharge of recovery and no post-dural puncture headache was detected.
Conclusions NA in severe AS is traditionally contraindicated due to sympatholytic effect that potentially lead to a diminished cardiac output. In our case, GA poses a great risk of morbimortality, due to patient age and comorbidities. By incremental minimal doses, CSA achieves a meticulous level and duration of block without excessive sympathectomy, while avoiding adverse effects of GA.
NA is no longer contraindicated in patients with AS, and CSA may even become the gold- standard for patients with multiple comorbidities.
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