Anesthesia Management of an Elderly Patient with Permanent

Pacemaker Undergoing an Open Reduction and Internal Fixation

Surgery:
a Case Report
Rene Aristyo Harjoa *, I Wayan Widanab,

a,b
Department of Anesthesiology, Wangaya General Regional Hospital, Bali, Indonesia

*
Corresponding author: dr. Rene Aristyo Harjo, Department of Anesthesiology, Wangaya General Regional Hospital,

Denpasar, Bali, Indonesia

Email address: rene.aristyo@gmail.com

Abstract

Introduction: In recent years, we have had significant population growth of older individuals all
over the world. The proportion of individuals above 60 years old continues to get bigger each year.
The average life expectancy keeps increasing, alongside with bigger challenges. The impact of
aging on the practice of medicine, especially the practice of anesthesia pose a far-reaching
challenge to all anesthesiologists. Older patients require different anesthetic management than
younger adults. Diminished organ function, systemic problems and change in body composition
must be taken into considerations when giving anesthestic management. Anesthesia in elderly
patients often come with more than one systemic problem.

Case: We present a case of a 75-year old female scheduled for an open reduction and internal
fixation (ORIF) surgery with plate and screws due to a closed fracture of right distal radius. She
presented to the orthopaedic polyclinic. Patient with a chief complaint of falling on her right
outstretched hand about a week ago. She complains of pain and swelling on her right wrist. The
patient denies other injuries. From her history of past illness, it is known that the patient has a
history of type II diabetes mellitus and controlled with Metformin 500 milligrams, three times a
day, and a hypertension controlled with Amlodipine 10 milligrams, taken once a day. She also has
a history of pacemaker implantation surgery about 4 months ago, due to a total atrioventricular
block. General physical examination confirms vital sign of high blood pressure of 150/80 mmHg,
other vital signs and general examination are normal. On local physical examination, on the right
wrist region, on inspection she was noticed to have deformity and swelling on her wrist, and
tenderness on palpation, the movement of the wrist is limited due to pain and swelling. Diagnostic
test of chest X-ray shows a implanted pacemaker. During the preoperative visit, the patient is
planned for brachial plexus block of the right arm. On the day of the surgery, the patient was
anesthetized using the peripheral nerve block technique with the injection site on the brachial
plexus of the right arm, using ultrasound-guided technique. The surgery went down for about 100
minutes. The patient was transferred to the Intensive Care Unit for intensive monitoring. The
patient was discharged from the intensive care unit the next day, and moved to the general ward.
She was discharged 3 days after.

Discussion: In patients with complex systemic problems, planning an anesthetic management

could be difficult and challenging for the anesthesiologist. In patients with multiple systemic
problems and organ dysfunction, the use of more common anesthesia technique like the general
anesthesia may increase risks and morbidity.

Conclusion: The use of regional anesthesia in certain cases are found to be more beneficial and
less harmful to the patients.

Keyword: Orthopaedic, ORIF, Peripheral Nerve Block, Pacemaker, Regional Anesthesia

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