Ultra-low-dose spinal anaesthesia for elective hip arthroplasty in a patient with severe pulmonary hypertension

Pulmonary hypertension is a complex chronic cardiopulmonary disease. The condition is an independent risk-factor for peri-operative morbidity and mortality in patients undergoing non-cardiac surgery, with mortality rates of up to 18%. Due to this, patients with pulmonary hypertension are frequently counselled against undergoing all but essential surgery. In this report, we describe the use of ultra-low-dose spinal anaesthetic delivered via intrathecal catheter to allow a patient with severe pulmonary hypertension to safely undergo an elective primary hip arthroplasty for osteoarthritis which was causing intolerable pain. The use of an intrathecal catheter avoided general anaesthesia in a patient who may not have tolerated positive pressure ventilation. The technique also allowed the use of ultra-low doses of spinal anaesthesia, with the option of titrating to effect and duration of surgery. Invasive monitoring allowed proactive management of the haemodynamic effects of neuraxial anaesthesia, specifically the fall in systemic vascular resistance that may be associated with higher doses of spinal anaesthesia. While this report describes a patient with severe pulmonary hypertension, the technique may also be considered for patients with other obstructive cardiac lesions including severe aortic or mitral stenosis.