A 76-year-old woman, AA, presented to our orthopedic clinic with a 6-year history of bilateral knee pain. The pain was dull, aching, and severe in intensity (the numerical rating scale was 8/10), and it prevented her from sleeping despite optimal analgesics. Though there was no associated hip pain, she could only move within her room with the aid of a walking frame and support from relatives. She also complained of poor appetite, weight loss, and easy fatiguability from minimal exercise.

She developed a peptic ulcer due to chronic use of NSAIDs; she was diagnosed as hypertensive 2 years prior to presentation, but she is neither diabetic nor asthmatic. She was on analgesics (tenoxicam 20 mg daily, dihydrocodeine 40 mg twice daily, and paracetamol 1 g thrice daily) and nifedipine 20 mg daily. There was a history of drowsiness due to the use of tramadol and chlorpheniramine, and she experienced a fixed drug eruption from consumption of chloramphenicol. She had two previous cesarean sections under general anesthesia; the last one was 40 years ago, during which she had blood transfusions.

A general physical examination revealed an elderly frail woman in mild respiratory distress (RR of 28 cycles per min), pale but not dehydrated, anicteric, and with nil pedal swelling. She had bilateral small-volume radial pulses, her blood pressure was 105/68 mmHg, she had positive hepatojugular reflux, and her heart sounds were S1, S2, and S4, with an ejection systolic murmur heard loudest at the 2nd intercostal space and radiated to the neck. Carotid bruits were heard bilaterally, though louder on the left side. There was bilateral symmetrical chest movement, breath sound was vesicular, and peripheral oxygen saturation (SpO2) ranged between 92 and 95% in room air.

The patient had an antalgic gait with severe wasting of the quadriceps, hamstrings, and calf muscles. There was a restricted range of motion in both knee joints with patellofemoral crepitus, but a fair range of motion was observed at both hip joints with increased tone globally. However, ankle clonus was absent.

Doppler ultrasound scan of the carotid arteries revealed severe stenosis of both carotid arteries (88% stenosis at the bulb of the internal carotid artery and 86% stenosis at the common carotid artery on the left side and 82% stenosis at the distal common carotid artery bulb on the right side). The electrocardiogram showed left ventricular hypertrophy and cardiac ischemia with anterolateral infarct. Echocardiography showed severe aortic stenosis (0.8 cm2) with a markedly reduced ejection fraction of 30%. An X-ray of both knee joints revealed severe osteoarthritis; packed cell volume was 31%, but results of other laboratory investigations were within the normal range. She was initially counseled for aortic valve replacement before total knee replacement, but the patient and her relatives refused the valvular procedure and opted for only the limb surgery.

Pre-anesthetic evaluation revealed a known hypertensive with aortic stenosis and bilateral carotid artery stenosis, diagnosed with bilateral severe osteoarthritis with the American Society of Anesthesiologists category IV, Mallampati (MP) score II, and Goldman cardiac risk index class IV (29 points). She was counseled for bilateral total knee replacement under segmental titrated epidural anesthesia.

In the operating room, a quick anesthetic check was done, and the patient was connected to a multiparameter patient monitor, and baseline blood pressure (BP), pulse rate (PR), and peripheral oxygen saturation (SpO2) measured were 105/68 mmHg, 70 bpm, and 98%, respectively. Venous access was secured on the volar surface of the forearm with a 16-G canula for fluid maintenance, replacement of ongoing losses, and probably for resuscitation. Appropriate resuscitation drugs and airway equipment were made available.

In a sitting position with the patient’s feet on a stool and under strict aseptic technique, the L4–L5 intervertebral space was located, and an epidural catheter was inserted with 4 cm left in the epidural space. Three milliliters of 1% lidocaine in 200,000 adrenalines were first administered as a test dose to eliminate the possibility of intrathecal or intravascular injection. Thereafter, epidural anesthesia was achieved by injection of 2.5 mL of 0.5% plain bupivacaine in aliquots every 5 min until the level of the block reached the suprapubic region after 20 min. This level of the block corresponded to the T12 and L1 dermatomal segments achieved by the administration of plain bupivacaine, in aliquot, into epidural space (titrated segmental epidural anesthesia). Two-point-five milliliters of 0.5% plain bupivacaine as the only supplemental dose of the epidural anesthesia was administered 90 min after the activation dose.

Monitoring of blood pressure (BP) was done noninvasively every 3 min, while heart rate (HR), peripheral oxygen saturation (SpO2), and electrocardiogram (ECG) were monitored continuously. The patient was not preloaded with intravenous fluid prior to the establishment of epidural anesthesia, and the epidural anesthesia that may probably induce hypotension was managed with intraoperative dopamine infusion at 5 µg/kg/min throughout the surgery that lasted for 2 h and 25 min.

Fluid maintenance and replacement of ongoing losses were achieved with 0.9% normal saline. Intraoperative systolic and diastolic blood pressure ranged from 104 to 110 mmHg to 66 to 72 mmHg, respectively, throughout the surgery that lasted for 145 min. Verbal contact was maintained with the patient throughout the surgery, and the cognitive function of the patient was monitored by assessing her memory and orientation in time, place, and person every 20 min until the end of surgery. A tourniquet was applied on both thighs (for 70 and 65 min on the right and left, respectively) to reduce significant intraoperative bleeding, and the estimated blood loss was 100 mL.

The patient was transferred to the intensive-care unit (ICU), and multimodal postoperative analgesia was provided with intravenous morphine (2 mg every hour), infusion acupan (20 g every 8 h), and paracetamol (1 g every 8 h) in addition to epidural analgesia by intermittent administration of 5 mL of 0.125% plain bupivacaine every 2 h for 24 h after the surgery. On the second day in the ICU, epidural analgesia was discontinued, and oral analgesics were commenced (tab tramadol 50 mg every 8 h and tab paracetamol 1 g every 8 h), and she was subsequently discharged to a surgical ward on the third postoperative day and discharged home after a 7-day stay in the hospital. She began physiotherapy on her second postoperative day, which continued throughout her stay in the hospital and for 2 weeks after discharge. On her first follow-up visit in 4 weeks after surgery, she was able to walk by herself with the aid of crutches.