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Successful Use of Epidural Anesthesia Following Guideline-Based Anticoagulation Bridging for Hip Surgery in a Patient with Acute Pulmonary Embolism: A Case Report Ayudya Tarita Alda; Paramita Putri Hapsari; RTH Supraptomo
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 9 No. 8 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v9i8.1370

Background: The perioperative management of patients with acute pulmonary embolism (PE) requiring major surgery presents a formidable clinical challenge. Therapeutic anticoagulation, essential for treating PE, is a significant relative contraindication for neuraxial anesthesia due to the risk of spinal hematoma. General anesthesia, however, carries a high risk of hemodynamic collapse in patients with compromised cardiopulmonary reserves. This report describes the successful application of a multidisciplinary, guideline-adherent strategy to manage this complex clinical scenario. Case presentation: A 56-year-old, obese female (BMI 30 kg/m²) with an extensive history of cardiovascular disease—including hypertensive heart disease, prior myocardial infarction, and an aortic dissection repaired via EVAR—presented with a post-traumatic left hip dislocation. Her presentation was critically complicated by an acute massive pulmonary embolism, diagnosed via echocardiography, which revealed large thrombi in the pulmonary arteries, and confirmed with a chest X-ray showing a Westermark sign. The patient required an open reduction and repair of the hip. A collaborative, multidisciplinary plan was formulated to enable the use of epidural anesthesia. Her anticoagulation with rivaroxaban was stopped five days preoperatively and bridged with a therapeutic infusion of unfractionated heparin (UFH). The UFH was discontinued six hours before the procedure, and surgery proceeded only after confirming normalization of coagulation parameters (INR < 1.5). Epidural anesthesia was successfully administered, providing excellent hemodynamic stability throughout the surgery. The patient was monitored in a cardiac intensive care unit postoperatively, with no neurological or bleeding complications. Conclusion: This case demonstrates that epidural anesthesia is a viable and potentially superior option for high-risk patients with acute PE, provided that a meticulous, guideline-concordant anticoagulation bridging strategy is implemented. Successful outcomes in such complex cases are predicated on rigorous multidisciplinary planning, patient selection, and vigilant postoperative monitoring. This approach validates current safety guidelines rather than challenging them, showcasing their utility in enabling advanced anesthetic care.

Successful Use of Epidural Anesthesia Following Guideline-Based Anticoagulation Bridging for Hip Surgery in a Patient with Acute Pulmonary Embolism: A Case Report Ayudya Tarita Alda; Paramita Putri Hapsari; RTH Supraptomo
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 9 No. 8 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v9i8.1370

Background: The perioperative management of patients with acute pulmonary embolism (PE) requiring major surgery presents a formidable clinical challenge. Therapeutic anticoagulation, essential for treating PE, is a significant relative contraindication for neuraxial anesthesia due to the risk of spinal hematoma. General anesthesia, however, carries a high risk of hemodynamic collapse in patients with compromised cardiopulmonary reserves. This report describes the successful application of a multidisciplinary, guideline-adherent strategy to manage this complex clinical scenario. Case presentation: A 56-year-old, obese female (BMI 30 kg/m²) with an extensive history of cardiovascular disease—including hypertensive heart disease, prior myocardial infarction, and an aortic dissection repaired via EVAR—presented with a post-traumatic left hip dislocation. Her presentation was critically complicated by an acute massive pulmonary embolism, diagnosed via echocardiography, which revealed large thrombi in the pulmonary arteries, and confirmed with a chest X-ray showing a Westermark sign. The patient required an open reduction and repair of the hip. A collaborative, multidisciplinary plan was formulated to enable the use of epidural anesthesia. Her anticoagulation with rivaroxaban was stopped five days preoperatively and bridged with a therapeutic infusion of unfractionated heparin (UFH). The UFH was discontinued six hours before the procedure, and surgery proceeded only after confirming normalization of coagulation parameters (INR < 1.5). Epidural anesthesia was successfully administered, providing excellent hemodynamic stability throughout the surgery. The patient was monitored in a cardiac intensive care unit postoperatively, with no neurological or bleeding complications. Conclusion: This case demonstrates that epidural anesthesia is a viable and potentially superior option for high-risk patients with acute PE, provided that a meticulous, guideline-concordant anticoagulation bridging strategy is implemented. Successful outcomes in such complex cases are predicated on rigorous multidisciplinary planning, patient selection, and vigilant postoperative monitoring. This approach validates current safety guidelines rather than challenging them, showcasing their utility in enabling advanced anesthetic care.

Beyond the Block: Sequential Spinal Anesthesia and Dexmedetomidine-Ketamine TIVA for a Four-Hour Cesarean Section in a 157-kg Parturient Agung Nugroho; Ardana Tri Arianto; Paramita Putri Hapsari
Journal of Anesthesiology and Clinical Research Vol. 6 No. 2 (2025): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v6i2.801

Introduction: Cesarean delivery in super-obese parturients (BMI ≥ 50 kg/m²) presents a complex combination of anesthetic challenges, amplified by comorbidities like preeclampsia. The strong imperative to avoid airway instrumentation makes regional anesthesia the preferred technique. However, the finite duration of a single-shot spinal block poses a significant risk in unexpectedly prolonged procedures, requiring a pre-planned strategy for anesthetic extension. Case presentation: A 38-year-old G2P1 parturient with a BMI of 63.7 kg/m² presented for an emergency cesarean section for fetal hypoxia and preeclampsia. After a rapid multidisciplinary consultation, a deliberate decision was made to proceed with spinal anesthesia to mitigate profound airway risks. The surgery became unexpectedly complex, lasting four hours. As the spinal block regressed, a planned transition to an opioid-sparing total intravenous anesthesia (TIVA) with dexmedetomidine and ketamine was initiated. This technique preserved spontaneous respiration and provided excellent hemodynamic stability, even during a 2000 mL hemorrhage. Conclusion: This case highlights the value of anesthetic adaptability in high-risk obstetrics. A sequential spinal-TIVA technique offers a safe and effective alternative to a high-risk conversion to general anesthesia, emphasizing the importance of having a pre-planned contingency for insufficient neuraxial blockade in super-obese parturients. This approach underscores the necessity of multidisciplinary communication and patient-centered care in navigating complex obstetric emergencies.

Anesthetic Management of a Teenage Primigravida with Impending Eclampsia Undergoing Emergency Cesarean Section: A Comprehensive Case Report Paramita Putri Hapsari; Agung Nugroho
Journal of Anesthesiology and Clinical Research Vol. 7 No. 1 (2026): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v7i1.886

Introduction: Impending eclampsia represents a medical emergency requiring immediate maternal delivery to prevent progression to seizures and maternal-fetal compromise. The selection of an appropriate anesthetic technique for emergency cesarean section in severely preeclamptic patients remains clinically challenging, balancing the risks and benefits of regional versus general anesthesia. Case presentation: A 19-year-old primigravida at 35 weeks and 6 days of gestation presented with frontal headache, blurred vision, and nausea. Clinical evaluation revealed new-onset hypertension (131/81 mmHg), proteinuria (+2), and mild hypokalemia (3.4 mmol/L), consistent with impending eclampsia. Emergency cesarean section was performed under subarachnoid block utilizing heavy bupivacaine 15 mg with fentanyl 25 micrograms intrathecally. Hemodynamics remained stable throughout the operative period without vasopressor requirement. A male neonate was delivered with Apgar scores of 7-8-9 and a birth weight of 1825 grams. Both mother and infant had favorable postoperative outcomes with resolution of hypertensive crisis and normal neonatal transition. Conclusion: This case demonstrates the efficacy and safety of regional anesthesia in eclamptic parturients undergoing emergency cesarean delivery. Careful patient selection, appropriate drug dosing, and vigilant hemodynamic monitoring enable successful outcomes even in this high-risk scenario.

Ultrasound-Guided Combined Femoral and Popliteal-Sciatic Nerve Block for Foot Debridement in a Patient with Peripheral Arterial Disease, Heart Failure with Reduced Ejection Fraction, and Pulmonary Oedema: A High-Risk Case Report Heri Dwi Purnomo; Paramita Putri Hapsari; Muhammad Rizal Aulia
Open Access Indonesian Journal of Medical Reviews Vol. 6 No. 2 (2026): Open Access Indonesian Journal of Medical Reviews
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/oaijmr.v6i2.888

Peripheral arterial disease (PAD) in its advanced stage leads to critical limb ischaemia requiring operative debridement, and coexisting heart failure with reduced ejection fraction (HFrEF) and pulmonary oedema make general and neuraxial anaesthesia hazardous. We describe a 59-year-old man with three-vessel coronary artery disease previously treated by multiple percutaneous coronary interventions, HFrEF (ejection fraction 36%), hypertension, diabetes mellitus and bilateral PAD who presented with acute decompensated heart failure, pulmonary oedema and bilateral pleural effusion together with an extensive left foot ulcer requiring urgent debridement and necrotomy. An ultrasound-guided combined femoral and popliteal-sciatic nerve block was performed using 20 mL of 1.5% lidocaine and 20 mL of 0.25% bupivacaine. The patient remained conscious and haemodynamically stable with systolic blood pressure 90–110 mmHg, heart rate ~85 beats/min and SpO₂ 100%. The 60-minute procedure was uneventful with no local anaesthetic toxicity, new neurological deficit or respiratory compromise, and the patient was transferred to the high-care unit. Ultrasound-guided peripheral nerve blockade represents a cardiopulmonary-sparing anaesthetic strategy that can deliver adequate operating conditions for lower-extremity surgery in patients with PAD and severe cardiac and respiratory comorbidity. Keywords: Peripheral nerve block, Peripheral arterial disease, Heart failure with reduced ejection fraction, regional anesthesia, ultrasound guidance.

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