Anesthesia for Hip Fracture - Crash course with Dr. Hadzic
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- Опубліковано 9 лис 2021
- Hip fractures are a common, morbid, and costly event among older adults. Patients with hip fractures are typically operated on within 24 hours of admission. However, they typically present multiple comorbidities that may not be easily controlled before the needed hip surgery.
For these reasons, spinal anesthesia is usually the best anesthetic option, where not contraindicated by anticoagulation or the presence of neurologic symptoms. Expertly performed spinal anesthesia results in a more stable perioperative course than general anesthesia. More importantly, spinal anesthesia decreases inpatient mortality and pulmonary complications (Neuman MD, Anesthesiology 2012, Vol. 117, 72-92).
In this video, Dr. Hadzic describes NYSORA’s standardized anesthetic management of patients with hip fractures, which consists of a suprainguinal fascia iliaca block, and low-dose isobaric spinal with bupivacaine with the paramedian technique.
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Medicine is an ever-changing science. As new research and clinical experience broaden, changes in treatment and drug therapy are required. The authors and publisher have checked with sources believed to be reliable in efforts to provide accurate information within the available or accepted standards of care. However, given the possibility of human error or changes in medical practice, neither the authors nor the publisher, nor any other party involved in the preparation of this platform warrants that the information contained herein is in every aspect accurate or complete, and they disclaim all responsibility for any errors or omissions for the results obtained from the use of the information contained in this work. Readers are advised to confirm the information contained herein with other sources. For example, readers are advised to check the product information of each drug mentioned, and that any information contained on NYSORA's UA-cam channel is accurate.
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1. Supra Inguinal Facia Iliaca block.
(involves: Femoral NB + Lateral Femoral Cutaneous NB + Lumbar plexus block)
And
2. Spinal Anaesthesia.
Hi Admir, thanks for your fantastic videos and pearls of wisdom. I stopped using 10 mg of isobaric Bupivacaine because I had the occasional failure with the block setting too late and not extending high enough
I currently use 12,5 mg, inject quite fast at the L 3 level in a paramedian approach at the side to be operated with the bevel of the needle oriented towards this side, and halfway through injection I would barbotage one Milliliter of fluid.
Before injection. I would give 2 to 3 mg of Midazolam and 10 mg of normal Ketamine, the Ketamine seems to counteract the respiratory depression of Midazolam .
I would also use routinely suprainguinal l fascia Iliana block as described by you.
Greeting from South Tyrol, Meinhard
Hi Meinhard. Agree with you that 10 mg isobaric bupi 0.5% does have a slightly higher failure rate. However, that is a tradeoff for a super hemodynamically stable spinal, which we do in block room. Also, 12.5 mg lasts at least 1 hour longer to recover and discharge patients from PACU room to the ward. Also, our surgeons are quick. In one of the upcoming videos, we will feature management of the "failed", rather "patchy" spinal anesthetic. Cheers and thank you for sharing.
I always feel very thankful to you and other channels creating educational videos on youtube. Despite graduated from medical school for many years, I have still learnt a lot of things from them. I can do many things new for my patients and it works. Thank you again.
Glad you enjoy them and find them helpful!
Isobaric bupivicaine 0.5% is NOT indicated for spinal anesthesia according to the manufacturer. What’s your comment on that?
Thank you Dr Hadzic!!!! Love your insightful videos!
Thank you Yulia.
Thank you for the video doctor Zac .
thank.the nysora viedoes are the best i have ever watched.respect from china.
Glad you like them! Keep watching- a lot more is coming soon!
Im not sure I like the justification for isobaric bupivacaine. I believe that using hyperbaric allows you a greater proportion of the bupivacaine to preferentially block the fracture site so you get a denser block with less contralateral motor blockade on the good leg which is a better outcome. Also a high block is less likely with hyperbaric because you can simply keep the bed position slightly head up whereas with isobaric you have no control at all. I usually use ketofol for positioning and then do the spinal with hyperbaric and then perform a FIB at the end of the operation to get the most out of duration of analgesia i.e. minimise spinal + block overlap. Always good to see other people's practice.
Thank you for sharing. Whatever works in your practice is the best. One important difference with isobaric: you do NOT have to worry about positioning in any particular position. Isobaric spinal is the norm for our Centers. Best regards
First of all: fantastic video. Thank you. But we use thick marcaine (7-10 mg) and wait 15-20 minutes. It turns out a one-sided block. This is sufficient until the end of the operation. Before spinal anesthesia, usually under sedation, a femoral block is performed in combination with a lateral femoral nerve block or fascia iliaca compartment block. But for THR i prefer FIB at the end of operation too.
There is no evidence that recommend one over the other. There is a lot of theory behind but no relevant outcomes
@@alexbondarev8986 Good technique. In fact, the "isobaric" bupivacaine is not exactly isobaric, but slightly HYPObaric, so we get similar effect you are describing. However, the effect is not as pronounced as with specifically formulated HYPER (HEAVY) bupivacaine you use. In patients with spine pathology (e.g scoliosis), however, I believe that "isobaric" is more consistent with regards to effect and hemodynamics. I do agree with Santiago T below in that there is no documented evidence one way or the other.
Shamill Eanga Helill et al. 2019 show that isobaric bupiv has greater haemodynamic variability (albeit in obstetrics). I don't see why the opposite would be true in orthopaedics. Moreover, if there were no definitive evidence either way (omitting that which I've just offered) then surely the option with the definitive benefit i.e. unilateral blockade is the superior option until proven otherwise.
Very eye opening practical views to administer anaesthesia for hip fractues surgery sir. Thankyou.
🙏
Glad it was helpful!
I totally agree with you Mr. Hadzic!
Hi Rodrigo! Thank you for your comment! Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
DR. H, a fantastic presentation!!
Thanks for watching! Greetings!
Great video as always, waiting for a video on managing anticoagulated and doac patients with hip fractures
Hello Simoceci! Thank you this is a great suggestion. We will definitely put this on our list greetings to you and all your colleagues and make sure you subscribe to our channel so you don't miss these upcoming videos. Best regards from NYSORA.
brilliant explanation, thanks alot
Thanks for watching!
Hello Admir! I understood that in lateral fractures you perform fascia iliaca+ spinal. My question is in medials fractures, do you perform fascia+ peng + spinal?
Hi Admir. Wonderful Videos and great teaching!! I just have one question. You mention dosages for spinal between 10mg-15mg bupivacaine 0.5% isobaric without intrathekal adjunctives. However in almost all your videos you can clearly see a volume of always 3-4ml given. In this videos its 4ml so it would be 20mg!! Could you clarify which dosage you really administer? From the video it seems your practise differs from the nysora protocols? Im just curious which dose/volume you are using. Thanks for all your great content!! Best wishes. Alex
Dr. Hadzic, would PENG block combined with femoral cutaneous nerve block be a viable alternative here? How come you prefer the fascia iliaca block? Also, 10mg of 0,5% Ropivacaine for spinal seems bordering on the low end, volume wise. Do You ever have problems with height of block being too low?
I only do THR and TKR, I totally agree with every step, the only thing is the dose of isobaric bupivacaine, I know 10 mg will work fine, but to wait for 20 to 30 min for the spinal to work is a luxury I don't have
Agree. Must be done preop in block room to allow the spinal to set-in. The payback - is no rush, and no hypotension.
Another phenomenal video, thank you. We are in Chicagoland and an Orthopedic referral hospital, and do >3,000 total joints/year and use exclusively isobaric bupi (I dose a little higher) and I agree with your reasons and comments, especially the low incidence of hypotension (we also do them in a Holding area, and transport to the OR with full monitors). For our hip fractures (we may do 3-8 Ortho trauma cases/day in the Ortho trauma room) we do both Spinal’s (your technique) and generals (LMA with FIB if a pinning, ETT if a Bipolar), because the Spinal’s are incredibly labor intensive, as you have shown in the video, and not always practical to do.
One question, when you position lateral, for the spinal, do you position the fracture side down or up? I was taught down, because it fixates the broken hip and you can flex the unroken hip to get some curvature of the spine, but many of my colleagues do the opposite.
Thank you!
Hey Chacagoland Samuel. It has been a while since I have been to Kingston Mines blues club. That is awesome that we do many things similarly. We do 2,000 total hips/year + the same amount for knees. Our surgeons are TOP. TOtal hip replacement (primary) - skin to skin is 45 minutes max (anterior approach), for example. Here's the absolute stars for the hips on the world-class; Kristoff Corte, Hans Welters, Ronald Driesen from our European Hip clinci. Check the link at the end. One of our videos will feature total hip replacement surgery - it is a miracle what our group does. Trully. Cheers. heuppraktijk.be/en/prof-dr-kristoff-corten/
Great video as always. What is your approach when you cannot do a spinal (i.e. low platelets, hypocoagulants)? Do you wait for the reversal time/ administer platelets or do you have a different technique for those patients? I apologize if you already answered this question but from a quick browse of the comments I did not find any answer.
Hi Rui. In short, we NEVER reverse anticoagulation or administer platelets so that we can do spinal. If spinal is deemed to be MUCH better than GA for specific patients on anticogulants, a 27 Gauge spinal needle is what we use to do spinal anyway, without reversing. For patients where spinal is not essential, we do GA without waiting. Hope things helps and best regards
Dr. Hadzic, it is very nice to see your local protocol and see how important it is to NYSORA to have standard practice protocols. I would like to know if you have a protocol for patients that you do need to use general anesthesia (use of anticoagulants, impossible neuraxial anesthesia, patient refusal, etc.). What kind of anesthetics is usually done by your team, thinking about the challenges imposed by this patient population? Is it standardized too? And is the regional anesthesia technique provided the same (supra inguinal fascia iliaca block)?
Thank you for one more illustrative video!
Hi Lucas. Great to hear from you. Those are all great questions and they help us develop ideas for future programs. Yes, all our protocols are in the NYSORA Learning System: nysoralms.com/ as we can not feature figures and algorithms in this forum. Cheers
Thanks for a great video! I usually use spinal anesthesia with 0,05 mg fentanyl and 9 mg isobaric Ropivacain
We are really glad you are enjoying our work. Greetings!
Excellent video! Do you change the technique for patients with valvular disease or do you find no difference?
Hi Michael. Actually - no. We have a case series paper on THIS spinal technique in patients with valvular disease. However - every aspect of the spinal technique in the video is important for success. Best regards
Thank you from Vietnam. Great video! How about post operative analgesia management. Should we place a catheter for SIFI block? . In our center, we just apply SIFI block for positioning in hip fracture surgery, and place an epidural catheter for 3 days for post operative analgesia.
Greetings. Also an option. In our population, single injection SIFI block with 025% bupivacaine is usually sufficient. If Exparel were available for this, we would mix to prolong analgesia. Catheters do NOT work well for most fascial block as the interfascial distribution is crucial, and this is difficult to accomplish with an injection through a small catheter. Epidural is not an option at our institutions, as it interferes with early mobilization, urinary catheter, requires additional management and troubleshooting, etc. Again - whatever works in your institution is the right thing to do. Best regards
Good work. Thanks. What will you do differently if a patient has severe aortic stenosis? Walt.
Hey Walt, Thank you for your comment. Will post a separate post on Aortic stenosis and spinal anesthesia. Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
Great educational video as usual. I want ask if few minutes are enough to analgesia onset after fascia iliaca?
thanks
Hi there. It would take some 20 minutes to get the most out of analgesic potential of the SI fascia iliaca. Wating that long would be impractical Instead, we take the benefit of early analgesia to "take the edge off" and use a small dose of propofol 10-20 mg for positioning in the lateral position for spinal. By the time we are done with positioning and the effect of propofol wares off, the analgesia is significant enough for patients to lay still on their side for the spinal. Hope this clarifies. Best regards
Super. Thank you very much 😊
Hi Lucas, Keep watching- a lot more interesting contents are coming soon. Greetings!
Thank you.
Hey Andrew Johnson! Thank you for your comment! Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
What if the patient demands a general anesthesia and absolutely refuses a spinal for a very good reason?
Just to sharing in indonesia in geriatri we give first fentanyl 50 ug iv to reduce pain when position from supine to lateral decubition, Spinal anesthesia with 20 mg bupivacain hyperbarik ( we dont have isobarik bupi) with adjuvan morfin 50 mikrogram for post op pain. Bed slight up anti trendelenburg with spinocent 26 and slow injection so the block not to high and have one side block
I always put an epidural catheter and give dexmeditomidine . That is very good for post op delirium.
Hi Boba Prakash! That is really great. Thank you for sharing. We all get better this way. Make sure you subscribe to this channel; a lot more is coming soon! Greetings!
Excellent ! Your surgeons are very quick. How to prolong the anaesthesia when your surgeon is yet to acquire that speed ? Any adjuvants intrathecally ?
If you have a slow surgeon diamorphine or morphine are your most sensible additions along with max dosages of local at block sights with adrenaline
Alternatively. GA. Lol
Was thinking of opioid free alternative but morphine is really good choice🤓
Hi Arnold. The bupivacaine 0.5% is long enough - about 3 hours of anesthesia - never need to prolong. We do not use additives in CSF with bupivacaine. Best regards
Dear NYSORA enthusiasts! Suprainguinal block is dedicated for anterior approach to the hip. But what if surgeons perform hip replacement from posterior approach? What kind of block is dedicated for that kind of procedure? Best regards!
I once worked with an anesthesiologist who had the same “recipe” for all surgeries. Your approach to doing hip fractures is very reminiscent, and lacks the same imaginative variation for the patient’s pathology. Furthermore, why do a spinal on top of the fascia iliaca . If you’re going to do a spinal, add 0.2 mg Duramorph to the local ( I prefer spinal Marcaine) and be done with it. You can do the spinal in the lateral position without patient discomfort by giving a mg of midazolam, and just enough ketamine to make the turn without any patient complaint. The patient is, of course, fully monitored and receiving supplemental oxygen. I agree completely with the 22 ga spinal needle., and I can usually accomplish the SAB on the first advance of the needle. Supplement oxygen can continue with the nasal cannula or simple mask, but I prefer to give a small amount of propofol and place an LMA to insure adequate oxygenation and a reliable ETCO2 wave form. Maintenance of sedation is easily done via a low dose propofol infusion as no additional analgesia is needed. This technique will give complete pain relief for 18 to 24 hours, and much less ( if any) narcotic after that. However, we have two orthopedic surgeons who will not allow spinal anesthesia, because it “takes too long”. They are not willing to take the usual ten minutes in the OR to do this technique. They are very typical orthopedic surgeons who don’t care about post-op pain control, they just need to get the surgery done so they can move on to the next patient. THEREFORE, for them I do a fascia iliaca block using ultrasound in the preop holding area with sedation, monitors and supplemental oxygen. Then to the OR and a general anesthetic. I can tell the effectiveness of the block as vital signs and respirations will remain steady without a lot of added narcotic, if any at all. The single injection fascia iliaca block alone usually provides good to total pain relief well into the next day. I use 30 ml 0.5 % Ropivicaine with 4 mg Decadron added to extend the block.
Do you draw CSF after injection the bupivakain to be sure you are the right place? Thank you.
Yes. We always aspirate to confirm the position of needle, rotate 360 degree to assure position of the entire bevel inside intrathecal space, and aspirate at the end to affirm that we are still intrathecal. Best regards to you and your colleagues.
What is your take on the REGAIN trial?
Dang so is the pt actually awake for the blocks? Can u do a video that explains how a caudal block the meds go up the lumbar region as well as down into legs?
Hi Sherry! Thank you! This is a great suggestion. We will definitely put this on our list. Greetings to you and all your colleagues and make sure you subscribe to our channel so you don't miss these upcoming videos. Best regards from NYSORA!!
Sir please share some technique for stabilization of epidural catheter,especially in obese patient, so it may retain for one week post op, withoit dislodgment. Thanks
Hi Mudassar Iqbal! Thank you for the suggestion. We will definitely put this on our list. Greetings to you and all your colleagues and make sure you subscribe to our channel so you don't miss these upcoming videos. Best Regards from Nysora!
Interesting to see how other colleagues work. Some feedback:
- Your doses of AL seem too high in my opinion. 4 mg of hypobaric bupivacaine at 0.12% provide just a sensitive block (no motor, no sympathetic blocks) are enough in elderly and fragile patients.
- As in the previous example, is not mentioned that neuroaxial block is differential, you can choose if you have the three of them or not.
- Every time you aspirate, you are also diluting your AL.
Just some suggestions to think about. Cheers!
Hi Julia! Thank you for sharing. Indeed, we all do things differently; in the end - it is what works 4 you. Thank you for watching and do subscribe to the channel - we have a lot more coming up soon; let's share the experience, learn from each other, and all get better at what we do. Cool that we have this medium now to collaborate without barriers. Greetings from NYSORA!
*Unrelated question for any Doctor out there.* How many times can you use a steroid during a trigger point injection (ie. Solu-Medrol). Is 4 times a year okay?
your recommendation is a very elegant approach to this surgery, and would work great when teamed with a great surgeon. However, not all of us are blessed with an elegant surgical partner deserving of such an elegant anesthetic. This picturesque elegant anesthetic often evolves into a general when the case runs into the 4th hour. Then, that same surgeon would blame anesthesia for pushing his clinic back by 2 hours with all the regional anesthesia. The patients love that surgeon because they never felt much pain for their surgery.....🤦♂
Does doing an FIB prevent early mobilisation due to quadriceps weakness? How about giving a peng block instead?
Hey Shin Yuet Chong! Fascia Iliaca block blocks the femoral nerve and causes motor block of the quadriceps muscles. Therefore, we earlier mobilization is desired PENG block would be better choice. Thank you for asking this interesting question and feel free to share the channel with your colleagues. Greetings!!
Thank you from mexico, what is your opinion of ropivacaine on spinal anesthesia?
It is not approved for this indication, but otherwise, excellent choice, which we also sometimes use as 2x bupivacaine dose for patients where we want the spinal to be 30% shorter. Best regards.
Way less motor block, long sensitive block. Even useful for laparoscopy if hypobaric. In this case add proper sedation or block to avoid/reduce refered pain to the right shoulder. Give it a try 👌
Hi Dr Hadzic, I'm writing you from Chile, we do have a lot of patients, with hip fracture, most of them with comorbities, especially heart diseases in all forms, when any of our patients are extremally ill, we use continual spinal anesthesia (5 mg isobaric bupivacaine with 20-25 microgr fentanyl diluted to 5 ml with saline solution) and we inject 1 ml of isobaric 0,1% bupivacaine when first installed the catheter, then another 1ml before surgery begins, and normally 1 more and last ml during surgery. The hemodinamics are completely stable and we dont have post puncture headaches. The catheter is removed when surgery is done. My question is, do you think that there is much difference beetwen ethnias to explain such big difference in doses?, I'm pretty sure that 10 or 12,5 mg of isobaric bupivacaine are extremely high doses and our patients would certainly need vasoactive support after such dose. Thanks for your comments
Hey Carlos! “Thank you for sharing - great technique. We just did another patient with critical aortic stenosis under spinal - no hypotension. However, it is crucial to use low level (L4-5, L5-S1) and isobaric LA 9e.g. 0.5% bupivacaine 2 ml). Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
Thanks Dr Camacho, I’m from HKSAR, China. Please tell me the catheter you use for continual spinal anesthesia.
I do a PENG block instead of FIB
did he say 10 ml of isobaric spinal volume?
Please make videos about anesthesia in abdominal surgery 🙏
Thank you. This is a great suggestion! We will definitely put this on our list. Greetings to you and all your colleagues and make sure you subscribe to our channel so you don't miss these upcoming videos. Best regards from NYSORA!
Dr. Hadzic... you use isobaric bupivacaine without fentanyl?
Yes. We generally do not like additives for their unpredictable side-effect profile. Our practice is simply too busy to deal with the variability and such. Also, intrathecal opioids in men often necessitate bladder catheterization, which we are trying to avoid.
@@DRBLUESNYC anesthesia resident here, I had a spinal for an elective hydrocelectomy and I think they put sufentanil in the mixture because while I had perserved motor function, 8 hours later I was still unable to void (either due to paruresis and sharing a room with a couple of other patients or due to opioids in the mix), in the end they had to cathetherize me and there was more than 1000 mL in the urine collector... wouldn't recommend.
Can l use hyperbaric pubi ?&how much dose?
Yes. The dose in the elderly would be the same. However see the discussion above why we prefer isobaric. Best regards.
#NOF for THJR. Extreme opioid sensitivity w PONV.
Asked for preop ketamine 2mg/hr. 18 hr later surgery for THJR. Requested Spinal in sitting position w 20 mg ketamine, for positioning, isobaric bupivacaine. Propofol w ketamine sedation. Postop ketamine 2mg/hr till 100mg total infusion.
No adverse affects from ketamine. Postop only paracetamol & celecoxib. OFA perioperatively. Uneventul postop.
Hey Jay Pat! Good Strategy. Thank you for your comment! Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
Wow
I thought isobaric causes high block and therefore more hypotension compared to hyperbaric solution
This is what I believe also.
👍👍👍