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Regional Anaesthesia in High Risk Elderly Patients Undergoing Hip Surgery

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

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Regional Anaesthesia in High Risk Elderly Patients Undergoing Hip Surgery

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  1. Regional Anaesthesia in High Risk Elderly Patients Undergoing Hip Surgery Assoc Prof. PetcharaSundarathiti, 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 benefitto patients undergoing major orthopedic surgery. • Why Regional Anesthesia?

  3. Benefits of Regional Anesthesia and Analgesia • RA provides more stable CV hemodynamics. • RAA provides superior pain relief in both intraoperative and postoperative periods with a superior recovery profile and better patient satisfaction. • RA placed preoperatively may provide preventive analgesia. • RA can avoid ET intubation & mechanical ventilation, leading to less respiratory complications and less ICU demand . • RA attenuate stress responses and preserve immune response. • RAA reduces opioid-related complications. • 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. 2002;49(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. 2010;4(1):37-42.

  7. Rodger et al. reviewed of 141 RCT (9559 pts) showed a relative risk reductionin 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. 2010;4(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 anaesthesiais 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.

  10. 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 30:;452-457.

  11. 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 neuraxialanaesthesia.

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

  13. 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

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

  15. 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 1994;79:1165-1177

  16. 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.

  17. 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.

  18. ASRA ConferencePractice Guidelines • As thromboprophylaxis with warfarin is initiated, neuraxial blockcan 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.

  19. ASRA ConferencePractice 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.

  20. 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

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

  22. 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.

  23. Are we blamed for the delay?

  24. 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.

  25. Is it safe to perform neuraxial anesthesia? • Sympathetic blockade withspinal or epidural anesthesia may be poorly tolerated especially in - extreme aged patient - the presence of hypovolemia - heart diseases

  26. 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.

  27. Anesthesia is crucial to the management of these patients

  28. This situation has refocused our interests in regional anesthesia and analgesia with continuous peripheral nerve blocks (CPNB).

  29. 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.

  30. 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. 2005;441:250-5.

  31. 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).

  32. 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

  33. 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

  34. PNB as sole anaesthetic technique for hip surgery

  35. 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. 2000;25(2):158-62.

  36. 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. 1997;19(6):371-5.

  37. 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 (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.

  38. 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. 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.

  39. 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.

  40. 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

  41. 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.

  42. 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 1:200,000 (1:1) 20 ml was injected slowly in aliquots after aspiration.

  43. 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

  44. 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.

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