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Regional Anaesthesia in High Risk Elderly Patients Undergoing Hip Surgery

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Title: Anesthesia without paraplegia: One leg anesthesia Author: Acer Last modified by: Petchara Sundarathiti Created Date: 10/1/2009 3:14:24 PM – PowerPoint PPT presentation

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Title: Regional Anaesthesia in High Risk Elderly Patients Undergoing Hip Surgery


1
Regional Anaesthesia in High Risk Elderly
Patients Undergoing Hip Surgery
  • Assoc Prof. Petchara Sundarathiti, MD
  • Ramathibodi Hospital, Mahidol University
  • Bangkok, Thailand

2
Regional Anaesthesia in High Risk Elderly
Patients Undergoing Hip Surgery
  • Regional Anesthesia (RA) has long been known to
    be benefit to patients undergoing major
    orthopedic surgery.
  • Why Regional Anesthesia?

3
Benefits 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.

4
Introduction
  • 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.

5
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.
    200249(9)946-50.

6
Introduction
  • 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. 20104(1)37-42.

7
  • 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

8
Introduction
  • 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. 20104(1)37-42.

9
Introduction
  • Michel 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.
    200214(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. 201021(Suppl 4)S555-72.

10
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11
Introduction
  • Nevertheless, 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 30452-457.

12
Introduction
  • Major 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.

13
Introduction
  • The safety of neuraxial anaesthesia in high risk,
    elderly patients undergoing hip surgery
    regarding to intraoperative hypotension and
    anticoagulation therapy should be emphasized.

14
  • 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 20051001482-8

15
Spinal Hematoma
  • Spinal hematomas are rare but potentially
    devastating complication of neuraxial anesthesia,
    to cause spinal cord compression, resulting in
    paraplegia.

16
Spinal 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
    1994791165-1177

17
American 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.

18
American 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.

19
ASRA Conference Practice Guidelines
  • As thromboprophylaxis with warfarin is initiated,
    neuraxial block can be done when the INR islt1.4.
  • 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.

20
ASRA Conference Practice Guidelines
  • 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.

21
  • 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

22
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23
Fractured hip in CAD patient taking Plavix
  • Two questions to ask
  • Delay operation for 7 d after stopping plavix?
  • Is it safe to perform neuraxial anesthesia in an
    extreme aged, CAD patient with plavix?

24
Delaying Surgery, does this affect mortality?
  • Mortality associated with delay in operation
    after hip fracture.
  • BMJ 2006332947-950 ((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.

25
Are we blamed for the delay?
26
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.

27
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

28
Is it safe to perform neuraxial anesthesia?
  • The only method available to eradicate bleeding
    complication risk associated with neuraxial
    anesthesia, regardless of the patients
    anticoagulated state, would be to avoid the
    neuraxial technique and go for PNB alternatively.

29
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30
Anesthesia is crucial to the management of
these patients
31
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32
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33
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34
This situation has refocused
  • our interests in regional anesthesia and
    analgesia with continuous peripheral nerve blocks
    (CPNB).

35
  • 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) gt1.4 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 101250-4.

36
Evidence-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. 2005441250-5.

37
Advantages of PNB over Neuraxial Block
  • Avoid spinal hematoma (paraplegia)
  • Avoid PDPH and backache
  • Avoid hypotension or IV fluid load elderly, CAD,
    LV outflow tract obstruction (AS)
  • Avoid narcotic-related side effects PONV,
    dizziness and urinary retention
  • Provide site specific anesthesia and analgesia
  • (one-leg anesthesia).

38
Advantages 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

39
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

40
  • PNB as sole anaesthetic technique for hip surgery

41
Sole 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. 200025(2)158-62.

42
Sole 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.
    199719(6)371-5.

43
Sole anaesthetic technique
  • Buckenmaier 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 (327102 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. 200017(2)158-62.

44
Anatomy
  • To 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.
    197645(1)95-9.
  • Birnbaum K, Prescher A, Hessler S, Heller
    KD. The sensory innervation of the hip joint--an
    anatomical study. SurgRadiol Anat.
    199719(6)371-5.

45
Clinical study at Ramathibodi Hospital
  • We retrospectively reported
  • 70 traumatic hip fracture
  • High risk, elderly patients, ASA PS III-IV
  • To determine
  • the efficiency of CLSB as sole anaesthetic
  • the safety and the complication related to
    CLSB
  • the patient outcomes.







46
Comorbidity
  • 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

47
CLSB 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.

48
CLSB 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 1200,000 (11) 20 ml
    was injected slowly in aliquots after aspiration.

49
CLSB 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

50
Result
  • 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.

51
Result
  • 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.

52
Result
  • The operation time lasted for 1-5.5 hr
    (mean 3.16SD1.02 hr).
  • Right after operation, all patients were awake
    with hemodynamically stable and stayed at PACU
    30-60 min before transfer to ICU or ward.

53
Result
  • The rescue drugs required for pain the first 24
    hr
  • morphine (mean 4.11SD1.98 mg) in 34 pts
    tramadol (mean 73SD17.00 mg) in 16 pts
    fentanyl (mean 31.25SD12.5 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.

54
Result
  • There 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.

55
Result
  • 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)

56
Result
  • We have not found any incidences of
  • nerve injury
  • epidural spread
  • local anesthetic toxicity
  • bleeding complication related to needle
    insertion ex retroperitoneal haematoma

57
  Discussion
  • CLSB 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.

58
Discussion
  • Until 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.

59
Discussion
  • 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.

60
Conclusion
  • 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.

61
Conclusion
  • 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.

62
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