Psoas compartment block for intramedullary supracondylar nailing for fracture shaft femur in an 80-year-old patient with severe ischaemic heart disease, hypertension, COPD and anaemia

Sir, Orthopaedic surgery is an expanding surgical specialty with a potentially difficult patient population. Regional anaesthesia is becoming increasingly popular as it offers several advantages over general anaesthesia, like providing post-operative analgesia, early rehabilitation, early hospital discharge and avoiding complications of general anaesthesia. We report a case of an 80-year-old male, weighing 35 kg, posted for intramedullary supracondylar nailing of femur for femur shaft fracture on right side (incision site: knee joint). On pre-anaesthetic check-up,the patient had low-volume pulse (72/min, regular) with blood pressure 170/102 mmHg and pursed lip breathing with respiratory excursion of 2 cm. Air entry was decreased bilaterally with presence of rhonchi occasionally. Patient was not on any medication previously and therefore medical treatment was started in the form of Tab spironolactone 25 mg OD, Tab enalapril 5 mg ½ HS, Tab frusemide 40 mg OD, Tab aspirin 325 mg ½ OD, Tab sorbitrate 10 mg TDS, Tab carvedilol 3.123 mg OD and Tab atorvastatin 20 mg HS. His investigations revealed haemoglobin of 8.6 gm%. Electrocardiogram showed complete left bundle branch block and chest X-ray revealed chronic obstructive pulmonary disease (COPD) changes with bilateral minimal pleural effusion. 2D-echocardiography showed mild mitral regurgitation + mild tricuspid regurgitation + mild pulmonary arterial hypertension + diastolic dysfunction with severe global hypokinesia and left ventricular hypertrophy with reduced ejection fraction (30%). After an initial period of stabilization, the patient was taken for surgery. A high-risk consent was taken for anaesthesia and the management was started. Peripheral nerve stimulator-guided psoas compartment block was given, with the patient being in a left lateral decubitus position, under all aseptic and antiseptic precautions. Inj. lignocaine 2% 12 cc + Inj. bupivacaine 0.5% 8 cc +10 cc sterile water were taken and given after placing the needle satisfactorily as guided by the peripheral nerve stimulator (PNS) locator. (Twitches of ipsilateral quadriceps muscle with current of 0.3 mA was considered as the end point.) Sensory block was confirmed by the pin prick method. After achieving adequate sensory blockade, the surgery was started. Surgery time was 65 min with 300 mL blood loss, which was replaced by whole blood. Throughout the procedure, ECG monitoring was performed, which did not show any episode of arrhythmia/ischaemic changes. The patient was comfortable during surgery and was covered with antibiotics pre-operatively. Post-operatively, the sensory block lasted for 3 h and pain relief lasted for 8 h approximately. During the whole post-operative period, the patient was stable, having no other complications. At the end of 7 days, he was discharged to home. Psoas compartment block, also known as lumbar plexus block, produces anaesthesia of lower extremity in distribution of femoral nerve, obturator nerve and lateral cutaneous nerve of thigh thus making a patient amenable to surgery over hip joint and knee joint. Jankowski et al. reported spinal anaesthesia and psoas compartment block to be superior to general anaesthesia when considering resource utilization, patient satisfaction and post-operative analgesic management for outpatient knee arthroscopy.[1] In a metaanalysis, Touray et al. described that psoas compartment block is a safe and effective alternative for analgesia after hip and knee surgery and more research is required to define its role in the intraoperative setting and confirm potentially beneficial effects on variables such as perioperative haemodynamics and blood loss.[2] de Visme and colleagues reported that combined psoas compartment block and sciatic nerve block compared with spinal anaesthesia resulted in less hypotension and improved analgesia in elderly patients undergoing hip fracture repair.[3] In a study by Jankowski and colleagues,[1] patients undergoing knee arthroscopy with psoas compartment block had less post-operative pain, greater satisfaction and less post-operative recovery room admission rates compared with general anaesthesia. In high-risk patients where indications and contraindications of general anaesthesia as well as central neuroaxial block are present, psoas compartment block as a sole induction technique is promising and could be considered as a viable option.