Regional Anaesthesia in High Risk Elderly Regional Anaesthesia in High Risk Elderly Patients Undergoing Hip SurgeryPatients Undergoing Hip Surgery

Regional Anaesthesia in High Risk Elderly Regional Anaesthesia in High Risk Elderly Patients Undergoing Hip SurgeryPatients Undergoing Hip Surgery

Assoc Prof. Petchara Sundarathiti, MDAssoc Prof. Petchara Sundarathiti, MDRamathibodi Hospital, Mahidol UniversityRamathibodi Hospital, Mahidol University

Bangkok, ThailandBangkok, Thailand

Regional Anaesthesia in High Risk Elderly Regional Anaesthesia in High Risk Elderly Patients Undergoing Hip SurgeryPatients Undergoing Hip SurgeryRegional Anaesthesia in High Risk Elderly Regional Anaesthesia in High Risk Elderly Patients Undergoing Hip SurgeryPatients Undergoing Hip Surgery

Regional Anesthesia (RA) has long been known to be benefit to patients undergoing major orthopedic surgery.

Why Regional Anesthesia?

Benefits of Regional Anesthesia and AnalgesiaBenefits of Regional Anesthesia and AnalgesiaBenefits of Regional Anesthesia and AnalgesiaBenefits of Regional Anesthesia and Analgesia

1. RA provides more stable CV hemodynamics.

2. RAA provides superior pain relief in both intraoperative and postoperative periods with a superior recovery profile and better patient satisfaction.

3. RA placed preoperatively may provide preventive analgesia.

4. RA can avoid ET intubation & mechanical ventilation, leading to less respiratory complications and less ICU demand .

5. RA attenuate stress responses and preserve immune response.

6. RAA reduces opioid-related complications.

7. Superior pain relief may reduce unplanned hospital admission.

IntroductionIntroduction IntroductionIntroduction

The majority of people suffering hip fracture are elderly.

Most hip fractures are treated surgically which required anaesthesia, and are associated with a severe impact on morbidity and mortality in the geriatric population.

Introduction Introduction Introduction Introduction Outcome is affected by multiple factors such as

pre-existing diseases, type of surgery and anaesthesia, and quality of perioperative care.

Besides the GA and neuraxial block techniques, recently the combined lumbar plexus and sciatic nerve block (CLSB) technique is recommended especially for high-risk patients.

Ho AM, Karmakar MK. Combined paravertebral lumbar plexus and parasacral sciatic nerve block for

reduction of hip fracture in a patient with severe aortic stenosis. Can J Anaesth. 2002;49(9):946-50.

IntroductionIntroductionIntroductionIntroduction

Potential outcome-influencing factors are : mortality

: deep vein thrombosis (DVT)

: pulmonary embolism

: postoperative confusion

Shih YJ, Hsieh CH, Kang TW, Peng SY, Fan KT, Wang LM. General Versus Spinal Anesthesia: Which is a Risk Factor for Octogenarian Hip Fracture Repair Patients? Int J Gerontol. 2010;4(1):37-42.

Rodger et al. reviewed of 141 RCT (9559 pts) showed a relative risk reduction in several complications within 30 days of surgery compared to GA. (for repair of hip fractures.)

Complication Risk reduction

Mortality 30%

Blood loss 55%

Respiratory depression 59%

Pneumonia 39%

DVT 44%

Pulmonary embolus 55%

MI 33%

IntroductionIntroduction IntroductionIntroduction

Total mortality following traumatic fractures in geriatric patients can be as high as 20% with a peak between day 6 and 16 (evidence level).*

Congestive heart failure, myocardial infarction, pneumonia and pulmonary embolism are the most common causes of death.

*Shih YJ, Hsieh CH, Kang TW, Peng SY, Fan KT, Wang LM. General Versus Spinal Anesthesia: Which is a Risk Factor for Octogenarian Hip Fracture Repair Patients? Int J Gerontol. 2010;4(1):37-42.

IntroductionIntroduction IntroductionIntroductionMichel et al. reported that in 114 pts treated for

hip fracture, high ASA (III or IV) conferred a nine times increased risk for mortality at 1 yr.*

Neuraxial anaesthesia is associated with a

significantly reduced early mortality, fewer incidences of DVT, acute postoperative confusion and fatal pulmonary embolism. **

* Michel JP, Klopfenstein C, Hoffmeyer P, Stern R, Grab B. Hip fracture surgery: is the pre-operative American Society of Anesthesiologists (ASA) score a predictor of functional outcome? Aging Clin Exp Res. 2002;14(5):389-94.

** Luger TJ, Kammerlander C, Gosch M, Luger MF, Kammerlander-Knauer U, Roth T, et al. Neuroaxial versus general anaesthesia in geriatric patients for hip fracture surgery: does it matter? Osteoporos Int. 2010;21(Suppl 4):S555-72.

IntroductionIntroduction IntroductionIntroductionNevertheless, there are also

disadvantages such as intraoperative hypotension, which may lead to CVA or MI, inadequate RA and urinary retention, as well as the rare complications such as epidural hematoma or infection.*

* Singelyn FJ, Ferrant T, Malisse MF, Joris D (2005) Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total hip arthroplasty. RegAnesth Pain Med 30:;452-457.

IntroductionIntroduction IntroductionIntroductionMajor orthopedic surgery induces a

hypercoagulable state and the incidence of intraoperative thrombosis formation is improved with the use of RA.

Perioperative pharmacologic anticoagulation therapy might be a contraindication for neuraxial anaesthesia.

IntroductionIntroduction IntroductionIntroduction

The safety of neuraxial anaesthesia in high risk, elderly patients undergoing hip surgery regarding to intraoperative hypotension and anticoagulation therapy should be emphasized.

In 1993, with the introduction of low molecular weight heparin (LMWH) in the USA, there was a significant increase in the incidence of spinal hematomas after neuraxial anesthesia.

Rowilingson JC, Hanson PB. Neuraxial anesthesia and LMWH prophylaxis in major orthopedic surgery in the wake of latest American Soceity of Regional Anesthesia guidelines. Anesth Analg 2005;100:1482-8

Spinal Hematoma Spinal Hematoma Spinal Hematoma Spinal Hematoma

Spinal hematomas are rare but potentially devastating complication of neuraxial anesthesia, to cause spinal cord

compression, resulting in paraplegia.

Spinal HematomaSpinal Hematoma Spinal HematomaSpinal Hematoma The chance of neurological recovery from

paraplegia was reported only in those patients in whom decompression laminectomy took place within 8 hours of the onset of symptoms.

The report by Vandermeulen et al. also showed that at least 50% of all patients will have a poor prognosis, with 26% mortality rate from this complication.

Vandermeulen EP et al. Anticoagulants and spinal –epidural anesthesia. Anesth Analg 1994;79:1165-1177

American Society of Regional AnesthesiaAmerican Society of Regional Anesthesia American Society of Regional AnesthesiaAmerican Society of Regional Anesthesia

The devastating nature of spinal hematomas prompted the American Society of Regional Anesthesia and Pain Medicine (ASRA) to convene a Consensus Conference on Neuraxial Anesthesia and Anticoagulation in 1998 for the purpose of establishing practice guidelines.

American Society of Regional AnesthesiaAmerican Society of Regional AnesthesiaAmerican Society of Regional AnesthesiaAmerican Society of Regional Anesthesia

Armed with this information, clinicians who desired their anticoagulated patients to receive the benefits of neuraxial anesthesia could proceed with confidence, knowing that the risk of bleeding complications had been minimized.

ASRA ConferenceASRA Conference Practice GuidelinesPractice GuidelinesASRA ConferenceASRA Conference Practice GuidelinesPractice Guidelines

1. As thromboprophylaxis with warfarin is initiated, neuraxial block can be done when the INR is<1.4.

2. Unfractionated heparin administration should be delayed for 1 h after needle placement and indwelling neuraxial catheters should be removed 2-4 h after the last heparin dose.

ASRA ConferenceASRA Conference Practice GuidelinesPractice GuidelinesASRA ConferenceASRA Conference Practice GuidelinesPractice Guidelines

3. Preoperative LMWH, the needle placement should occur at least 10-12h after the prophylaxis dose and at least 24h after the treatment dose.

4. The suggested time interval between discontinuation of thienopyridine therapy and neuraxial blockade is 14 days for ticlopidine and 7 days for clopidogrel.

93 years old, female, FC II-III

DM, HT, DVD (recent CHF-1 wk)

Chronic renal failure, hypoalbuminemia

Aspirin and Plavix

Dx: Fractured neck of femur, Rt

Op: Bipolar hemiarthroplasty

Fractured hip in CAD patient taking PlavixFractured hip in CAD patient taking PlavixFractured hip in CAD patient taking PlavixFractured hip in CAD patient taking Plavix

Two questions to ask

1.Delay operation for 7 d after stopping plavix?

2.Is it safe to perform neuraxial anesthesia in an extreme aged, CAD patient with plavix?

Delaying Surgery, does this affect mortality?Delaying Surgery, does this affect mortality? Delaying Surgery, does this affect mortality?Delaying Surgery, does this affect mortality?

Mortality associated with delay in operation after hip fracture.

BMJ 2006;332:947-950 ((Dr Foster)

-130,000 cases, 18,500 deaths in hospital (14.3%)

(April 2001 to March 2004)

Delay in operation associated with increased risk of death in hospital.

Are we blamed for the delay? Are we blamed for the delay?

Is it safe to perform neuraxial anesthesia?Is it safe to perform neuraxial anesthesia? Is it safe to perform neuraxial anesthesia?Is it safe to perform neuraxial anesthesia?

The consensus statements are designed to encourage safe and quality patient care, but cannot guarantee a specific outcome.

Regrettably, minimization does not equate to elimination of risk.

Is it safe to perform neuraxial anesthesia?Is it safe to perform neuraxial anesthesia? Is it safe to perform neuraxial anesthesia?Is it safe to perform neuraxial anesthesia?

Sympathetic blockade with spinal or epidural anesthesia may be poorly tolerated especially in

- extreme aged patient

- the presence of hypovolemia

- heart diseases

Is it safe to perform neuraxial anesthesia?Is it safe to perform neuraxial anesthesia?Is it safe to perform neuraxial anesthesia?Is it safe to perform neuraxial anesthesia?

The only method available to eradicate bleeding complication risk associated with neuraxial anesthesia, regardless of the patient’s anticoagulated state, would be to avoid the neuraxial technique and go for PNB alternatively.

Anesthesia is crucial to the management Anesthesia is crucial to the management of these patients of these patientsAnesthesia is crucial to the management Anesthesia is crucial to the management of these patients of these patients

This situation has refocusedThis situation has refocusedThis situation has refocusedThis situation has refocused

our interests in regional anesthesia and analgesia with continuous peripheral nerve blocks (CPNB).

In the study of Chelly and colleagues described their experience in 670 patients receiving lumbar plexus CPNB for total hip surgery along with warfarin thromboembolic prophylaxis.

One-third of the patients in the Chelly and colleagues study had an international normalized ratio (INR) >1.4 which is the highest Conference recommended limit for the removal of neuraxial catheters. There were no catheter-related bleeding complications.

Chelly JE et al. International normalized ratio and prothromin time values before the removal of a lumbar plexus catheter in patients receiving warfarin after total hip replacement. Br J Anaesth 2008; 101:250-4.

Evidence-based medicineEvidence-based medicine Evidence-based medicineEvidence-based medicine

A prospective survey of 103,730 patients reported a significantly lower incidence of serious complications, such as cardiac arrest and neurologic injury, in patients with PNBs compared with patients with neuraxial block.*

* Indelli PF, Grant SA, Nielsen K, Vail TP. Regional anesthesia in hip surgery. ClinOrthopRelat Res. 2005;441:250-5.

Advantages of PNB over Neuraxial BlockAdvantages of PNB over Neuraxial Block Advantages of PNB over Neuraxial BlockAdvantages of PNB over Neuraxial Block

1. Avoid spinal hematoma (paraplegia)

2. Avoid PDPH and backache

3. Avoid hypotension or IV fluid load: elderly, CAD, LV outflow tract obstruction (AS)

4. Avoid narcotic-related side effects: PONV, dizziness and urinary retention

5. Provide site specific anesthesia and analgesia

(one-leg anesthesia).

Advantages of PNB over Neuraxial BlockAdvantages of PNB over Neuraxial BlockAdvantages of PNB over Neuraxial BlockAdvantages of PNB over Neuraxial Block

6. Can be used in patients who have contraindication for neuraxial anesthesia

- post spinal surgery or back pain

- increased ICP

- bleeding dyscrasia: hemophilia (with US)

7. Improved physical therapy, mobility, functional recovery and facilitating early hospital discharge

8. Increase patient satisfaction

PNB guideline?PNB guideline? PNB guideline?PNB guideline?

The ASRA conference left the issue suggesting that neuraxial guidelines could be applied to PNB patients as a conservative approach while admitting this “may be more restrictive than necessary”.

May be more restrictive than necessary

PNB as sole anaesthetic technique for hip surgery

Sole anaesthetic techniqueSole anaesthetic technique Sole anaesthetic techniqueSole anaesthetic technique

As sole anaesthetic technique for hip surgery, the LPB (lumbar plexus block) is likely to be insufficient.

De Visme et al. described a substantial need for supplement opioids and sedatives for 27% of the patients undergoing hip fracture repair under LPB with additional sacral plexus block.*

* de Visme V, Picart F, Le Jouan R, Legrand A, Savry C, Morin V. Combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia for hipfractures in the elderly. RegAnesth Pain Med. 2000;25(2):158-62.

Sole anaesthetic techniqueSole anaesthetic techniqueSole anaesthetic techniqueSole anaesthetic technique

A meta-analysis by Touray et al. concluded that there was insufficient evidence for the use of CLSB (combined lumbar-sacral plexus

block) and sedation as an alternative to a GA or spinal anaesthetic for hip surgery.*

* Birnbaum K, Prescher A, Hessler S, Heller KD. The sensory innervation of the hip joint--an anatomical study. SurgRadiol Anat. 1997;19(6):371-5.

Sole anaesthetic techniqueSole anaesthetic technique Sole anaesthetic techniqueSole anaesthetic techniqueBuckenmaier III et al. concluded that a LPB with perineural

catheter and sciatic nerve block with perioperative sedation is effective alternative to GA for total hip arthroplasty.

However, the dose of propofol (50-200 mcg/kg/min) and fentanyl (327±102 mcg) used by the authors resemble GA instead of sedation.

Buckenmaier CC 3rd, Xenos JS, Nilsen SM. Lumbar plexus block with perineural catheter and sciatic nerve block for total hip arthroplasty. J Arthroplasty. 2000;17(2):158-62.

AnatomyAnatomy AnatomyAnatomyTo provide anaesthesia & analgesia to the entire

leg, a combination of a LPB; posterior approach and a high sciatic nerve block is necessary.*

The addition of this sciatic block to a LPB should also be valuable for hip surgery, because the posteromedial section of the hip joint capsule is partially innervated by branches of the sciatic n.**

*Chayen D, Nathan H, Chayen M. The psoas compartment block. Anesthesiology. 1976;45(1):95-9.

**Birnbaum K, Prescher A, Hessler S, Heller KD. The sensory innervation of the hip joint--an anatomical study. SurgRadiol Anat. 1997;19(6):371-5.

We retrospectively reported 70 traumatic hip fracture High risk, elderly patients, ASA PS III-IVTo determine

: the efficiency of CLSB as sole anaesthetic

: the safety and the complication related to CLSB

: the patient outcomes.

Clinical study at Ramathibodi HospitalClinical study at Ramathibodi Hospital Clinical study at Ramathibodi HospitalClinical study at Ramathibodi Hospital

ComorbidityComorbidity ComorbidityComorbidity: Currently taking anticoagulants 48

: Heart diseases 33

: Hypertension 40

: Vascular diseases 4

: Chronic kidney diseases 14

: Acute renal failure 3

: Respiratory diseases 8

: Old CVA 12

: Endocrine disorders 13

CLSB TechniqueCLSB Technique CLSB TechniqueCLSB Technique LPB

: the technique described by Capdevila

:18-G insulated Tuohy needle or 21-G needle for single shot technique (in anti-coagulated patients)

: was inserted & advanced perpendicular to the skin in all planes to contact the L4 T-processs.

: the needle is “walked off” either superiorly or inferiorly approximately 1-2 cm. deeper.

CLSB TechniqueCLSB Technique CLSB TechniqueCLSB Technique

: Using nerve stimulation, quadriceps contraction is obtained with a stimulating current of 0.4 mA

: Using in combination with US guided for anti-coagulated patients.

: A mixture of 0.5% levobupivacaine and 2% lidocaine with epinephrine 1:200,000 (1:1) 20 ml was injected slowly in aliquots after aspiration.

CLSB TechniqueCLSB Technique CLSB TechniqueCLSB Technique

Sciatic nerve block

: using the transgluteal or parasacral approach.

: A 100-mm, 21 gauge insulated needle was inserted, foot plantar flexion or dorsiflexion was elicited with a stimulating current 0.4 mA.

: The same LA mixture 20 ml was injected

ResultResult

ResultResult

We reported the successful used of CLSB as sole anaesthetic.

The need for GA was not encountered in all pts.There was one patient developed mild hypotension

and was treated with only ephedrine 5 mg IV.

ResultResult ResultResult

Intraoperatively, they needed only small doses of : midazolam (1-3mg) : fentanyl (25-50 mcg) and/or propofol (15-30 mcg/kg/min) without any additional airway maneuver or instrumentation.

The operation time lasted for 1-5.5 hr (mean 3.16±SD1.02 hr).

Right after operation, all patients were awake with hemodynamically stable and stayed at PACU 30-60 min before transfer to ICU or ward.

ResultResult

ResultResult

ResultResult

ResultResult The rescue drugs required for pain: the first 24 hr

: morphine (mean 4.11±SD1.98 mg) in 34 pts tramadol (mean 73±SD17.00 mg) in 16 pts fentanyl (mean 31.25±SD12.5 mcg) in 4 pts paracetamol (500 mg) orally only in 16 pts.

There were 36 patients admitted in ICU due to medical conditions and majority of the patients stayed only one nightlong.

ResultResult

ResultResultThere was one patient with septic prosthetic hip,

ASA IV, dead 2 months after surgery due to sepsis with pneumonia and uncontrolled atrial fibrillation.

All patients with pre-existing cognitive dysfunction

were stable as their base line except one patient who had psychological disorder progress worse and required psychologist attention.

ResultResultResultResult

Patient satisfaction with the anaesthetic technique was measured in all patients, except 11 patients who had pre-existing cognitive dysfunction, at Day1 postoperative period using a verbal rating scale (VRS 0-10). All patients rated as VRS≥ 8.

The median length of hospital stay was 5 days (max 60, min 3)

ResultResult ResultResult

We have not found any incidences of

: nerve injury

: epidural spread

: local anesthetic toxicity

: bleeding complication related to needle insertion ex: retroperitoneal

haematoma

  

DiscussionDiscussion  

DiscussionDiscussionCLSB should not be used routinely and

considered only when RA is strongly preferred but central neuraxial blocks are contraindicated.

It is important to consider risk-benefit on a patient-by-patient basis.

As with all anaesthetic procedures, complications rates reflect in part the skills and judgments of the operator.

DiscussionDiscussion DiscussionDiscussionUntil now, there is no published data

describing optimal dosing for LPB or sciatic block when using as the combined block technique.

Furthermore, one must exercise caution when considering a LPB in anti-coagulated patients, we used ultrasound guidance in combination with nerve stimulation for the blocks.

DiscussionDiscussion DiscussionDiscussion

The widespread use of anticoagulation in patients undergoing hip surgery mandates further research to make CLSB technique more optimal and more safety for hip anaesthesia.

ConclusionConclusionConclusionConclusion

The magnitude of the benefits of the CLSB is clinically important as sole anaesthetic for hip fracture surgery even in patients who have contraindication for neuraxial anesthesia or patients with poor general health status.

ConclusionConclusion ConclusionConclusion

The advantages of CLSB are encouraging technique to operate high risk, hip fracture patients.

We found a very good clinical efficiency of CLSB in hip surgery without any serious complications.

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