An 86-year-old female patient weighing 82 kg with 1-week-old right femoral neck fracture was scheduled for internal fixation or hemiarthroplasty. Medical history was significant for hearing loss, cerebrovascular event 7 years ago and severe aortic stenosis. Physical examination and laboratory tests were positive for Grade IV murmur on the aortic area and high serum creatinine (2.33 mg/dl). Peripheral arterial blood gases without O2 support were as follows: pH: 7.40, PaCO2: 38.3 mmHg PaO2: 66.7 mmHg and O2 saturation: 90%. Posterior-anterior chest X-ray showed right hilar widening, elevated left hemidiaphragm and an area of atelectasis/mass in the left basal segment. Initial electrocardiogram (ECG) revealed atrial fibrillation-flutter and a follow-up ECG demonstrated sinus rhythm. Patient was classified as being American Society of Anesthesiology Class 4. The patient and family were informed of the high risk of morbidity and mortality and written informed consent was obtained. After considering all comorbidities, general or spinal/epidural anaesthesia was considered to be of considerable risk. Therefore, a combination of peripheral nerve blocks was considered as alternatives. Premedication of 1 mg midazolam was performed. Invasive arterial pressure monitoring added to standard monitorisation plan.\nPatient was placed in the left lateral decubitus position. After aseptic precautions and skin preparation, the fourth lumbar vertebral spinous process was identified, and a low-frequency convex transducer was placed 4 cm lateral to the midline on the parasagittal plane. The transverse process and erector spinae muscles were visualised. A 10 cm 22G needle was advanced using the out-of-plane technique. After contact with the transverse process, local anaesthetic (0.5% bupivacaine 20 ml, 2% lidocaine 8 ml and 12 ml isotonic saline) was administered. Thereafter, the transducer was placed in the transverse plane on the flank of the patient cranial to the iliac crest. The fourth lumbar vertebral transverse process, erector spinae psoas and quadratus lumborum muscles were identified. A 15 cm 22G needle was inserted on the posterior corner of the convex probe. Twenty millilitres of local anaesthetic (0.5% bupivacaine 10 ml, 2% lidocaine 4 ml and 6 ml isotonic NaCl) was administered between the quadratus lumborum and psoas muscles. This ratio of LA was chosen considering toxic levels of each component and is customised for this patient.\nFollowing blocks, the patient was placed in the supine position. After 20 min, pinprick test revealed sensory block between T10 and L4 dermatomes. The patient was able to move her feet; however, there was no movement of the hip joint. The patient had no pain. There was no sensorial or motor block on the contralateral side, possibly excluding the presence of epidural spread. Surgery commenced at 35th min following nerve block. Partial hip prosthesis was performed in 2 h. Twenty-five micrograms of fentanyl was administered once for arterial line placement and once because of the slight increase in blood pressure, making the total administered dose 50 mcg. Interventions involving the medial aspect of the femur, innervated by the obturator nerve, led to mild pain and increments of 10 mg of intravenous ketamine was given totalling 40 mg. Post-operative analgesia plan included paracetamol that was administered every 8 h. Examination at postoperative 12th h revealed no pain at rest or on movement. Numeric Rating Scale was ≤2/10 for the first 16 post-operative hours during which time rescue analgesia was not required.
Case 1: A 38-year-old male (weight 75 kg, ASA status III) was scheduled for right total hip arthroplasty (THA) due to severe bilateral rigid and sore hip joints. He had a history of ankylosing spondylitis for more than 18 years. Despite a long term usage of sulfasalazine and “painkiller”, the patient developed a rigid kyphotic and scoliotic deformity. An overall physical examination revealed rheumatoid arthritis involved most articles in the body resulting in limited movement and swelling of interphalangeal joints, metacarpophalangeal joints, elbow joints, shoulder joints, and ankle joints, with rigid bilateral hip and knee joints preventing any walk. The airway assessment revealed a Mallampati class III, interincisor distance of 3 cm, and rigid neck incapable of any movement. X-ray of his cervical, thoracic and lumbar vertebrae and pelvis revealed a loss of physiological curvature of the vertebral column, kyphosis, hyperplasia at the edge of the vertebrae, “bamboo” like bony bridge, blurred facet joints, and calcification of ligament, a fusion of both sacroiliac joints, rough articular face and narrowed articular cavity and hyperplasia of both hip joints (Fig. ). After administration, he received immunosuppressive therapy, with prednisone 20 mg per day, and methotrexate 10 mg once per week, and anti-TNF therapy with etanercept (TNF receptor fusion protein) 25 mg i.h. twice per week, and anticoagulation therapy with low-molecular-weight heparin 4000 U per day.