Delayed Spinal Effect of Subarachnoid Blockade in a 103-years-old Female R. F. Ghaly MD, FACS, Z. McMillan, MD, A. Lapusca, MD, N. N. Knezevic, MD, PhD, K. D. Candido, MD Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL USA Discussion Abstract References Introduction Case Description Not much has been written regarding regional anesthesia in the extremely elder population. We present a case of delayed spinal effect of subarachnoid blockade in a 103 year old female who presented for left hip pinning after a fall. A 25G 5 inch Pencan spinal needle was used to identify the SAS after several attempts. Hyperbaric bupivicaine (1.5 mg of 0.75%) with 15 mcg of fentanyl was injected into the SAS. After 10 minutes, she had not developed a level of analgesia. The patient was placed in Trendelenburg and after 45 min developed adequate T12 anesthesia. Extreme elder present unique anesthetic challenges secondary to normal physiological and musculoskeletal deterioration. A delayed onset of neuraxial blockade in the elderly can be related to spinal stenosis, scoliosis, degenerative joint disease, or delayed diffusion through the dura and should be expected prior to conversion to general for failed SAB. In this case report, we showed that up to 45 min may be needed for adequate surgical anesthesia. There is a paucity of literature describing regional anesthesia in the extremely elder patient (>90 year old). With advances in medical care and the aging baby boomers, the prevalence of people living 95 years and older is expected to increase. This population presents unique regional anesthetic challenges secondary to physiologic deterioration, musculoskeletal contractures, degenerative joint disease, severe neuraxial musculoskeletal degeneration, autonomic regulatory dysfunction, cognitive dysfunction, and altered pharmacokinetics and pharmacodynamics. We present a case of a delayed onset of subarachnoid blockade in a 103 year old female patient undergoing left hip pinning of a femoral neck fracture. A 103 year old obese AA female from assisted living presented for left hip pinning of a femoral neck fracture after a fall from her wheelchair. Preoperative evaluation revealed an elderly woman moaning incomprehensibly in distress from discomfort. PMH was significant for hypertension, congestive heart failure, atrial fibrillation, osteoporosis, renal insufficiency, and right lower extremity lymphedema with cellulitis. Preoperative labs were significant for BUN 35, CR 1.75, BNP 63, albumin 3.3, Hg 9.4, platelets 113, and INR 1.1. The patient was taken to the OR and placed in the right lateral decubitus position. Approximately 500ml of NS was given as preload prior to spinal blockade. A 25G 5- inch Pencan  spinal needle was used to access the subarachnoid space, with free flow of clear CSF. Multiple attempts by an experienced (pain fellowship trained) anesthesiologist were necessary due to severe scoliosis and osteophytes. Hyperbaric bupivacaine, 1.5 ml of 0.75% (11.25 mg), with 15 mcg of fentanyl was injected. The patient was then placed in Trendelenburg and monitored for spinal level (Picture 1). Adequate analgesia was not reached for approximately 45 minutes at which time she developed a level at T12. Once a level was obtained, the surgery was uneventful and proceeded without complications. Conclusion General anesthesia in the elderly has been associated with prolonged cognitive dysfunction. There is little information in the literature regarding the effects of general or regional anesthesia on patients older than 95 years. Extremely elder patients often have multiple significant co-morbidities including pulmonary and cardiac disease, poor nutritional status, and baseline cognitive dysfunction. For these patients, regional anesthesia may be a safer anesthetic management option. The delayed effect of spread of local anesthetics in our patient may be related to severe spinal stenosis, scoliosis, or delayed diffusion through the dura. Patience and expected delays for spinal effect after subarachnoid blockade is suggested. Monitored Trendelenburg position may assist diffusion of local anesthetic into higher levels through stenotic regions. A delayed spread of local anesthetic after subarachnoid blockade in extreme elderly patients should be expected, and may be secondary to anatomical and physiological causes. In this case report, we showed that up to 45 minutes may be needed for adequate surgical anesthesia. P. Williams-Russo, et al. JAMA. 1995;274: A. Rodgers. BMJ 2000;321:1493 Hocking G, Wildsmith JAW. Bri J Anaesth 2004;93: JT Moller, et al. The Lancet, 1998;351: Factors Affecting the Level of Spinal Anesthesia Most important factors Baricity of anesthetic solution Position of the patient (during injection and immediately after injection) Drug dosage Site of injection Other factors Age CSF fluid Curvature of the spine Drug volume Intraabdominal pressure Needle direction Patient height Pregnancy Picture 1.