neuraxial for hip fractures

[Colba55o]

Can anyone offer advice on smoothly doing spinals or even epidurals on hip fracture patients that are in too much pain to move let alone position themselves?

I know regional provides better pain control, less DVTs, transfusions etc but I find it such a struggle to try to do spinals on these patients. Some of my colleagues say they give a propofol bolus before turning the patient into position, but I have found this either leads to desaturation or the patient becoming squirrely or disoriented just when I'm trying to put a needle in their back. Plus since its often done on the hospital bed before moving them onto the table, the positioning is suboptimal, the assistant and I straining our backs since the beds are wider. For those of you that do the propofol bolus thing are your patients fully awake when you begin to do the spinal?

Isn't it risky doing a spinal in a sedated patient? I know people to caudals and epidurals in peds under GA but I worry whether its worth the risk in this population. Id rather get a transfusion or a DVT rather than permanent nerve damage. Do you find that even in a sedated state the patient is able to get into a good tight curled fetal position or is the assitant doing most of the work?

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[pgg]

Ketamine works well. Doesn't talk much, a little nystagmus is a good end point.

Spinals in sedated patients are safe.

Fetal position isn't necessary. Most old people with hip fractures aren't obese - they have tough crunchy ligaments but finding a path in usually isn't hard, even without perfect positioning. It helps to use a bigger spinal needle than the 25 g one in the kits. Old people don't get PDPHs ... no reason not to use a 22 g needle.

I do the spinal broken hip up, with isobaric 0.5% bupiv, from the bottle that says "not for spinal use".

 

[nap$ter]

Can anyone offer advice on smoothly doing spinals or even epidurals on hip fracture patients that are in too much pain to move let alone position themselves?

I know regional provides better pain control, less DVTs, transfusions etc but I find it such a struggle to try to do spinals on these patients. Some of my colleagues say they give a propofol bolus before turning the patient into position, but I have found this either leads to desaturation or the patient becoming squirrely or disoriented just when I'm trying to put a needle in their back. Plus since its often done on the hospital bed before moving them onto the table, the positioning is suboptimal, the assistant and I straining our backs since the beds are wider. For those of you that do the propofol bolus thing are your patients fully awake when you begin to do the spinal?

Isn't it risky doing a spinal in a sedated patient? I know people to caudals and epidurals in peds under GA but I worry whether its worth the risk in this population. Id rather get a transfusion or a DVT rather than permanent nerve damage. Do you find that even in a sedated state the patient is able to get into a good tight curled fetal position or is the assitant doing most of the work?

this is why i don't do neuraxial blocks on hip fractures. LMA and fascia iliacus block with ultrasound (sometimes asleep) - 30mL 0.375% bupivicaine c decadron 6mg. half the time these patients are delirious or demented at baseline so asleep vs awake doesn't mean as much.

 

[dhb]

20-25mg of ketamine if you want to do a spinal, i agree that most of these patients are demented and GA + FI block is easier

 

[Dwindlin]

Not sure this helps you, but tangentially we have a decent "program" here where any hip fx get a FI catheter in the ED for pain control that stays with them through the OR to POD 2/3. Nice deal. Patients love it. Saves a ton of money because LOS is significantly decreased so admin loves it. Patients are moving with little no narcs POD 1/2 so surgeons love it. All around good stuff.


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[pgg]

I know regional provides better pain control, less DVTs, transfusions etc

Also, that's a dubious claim ...

Lots of these patients are on Plavix or otherwise have contraindications for neuraxial, so we often do them under GA.

GA plus a fascia iliaca block is Just Fine. I prefer a tube over LMA because I like the better vent control, but that's just quibbling over details. The GA/FI patients get out of PACU faster too ... I'm never disappointed when I'm forced to go GA.

 

[BLADEMDA]

I do these cases under both GA/ LMA and SAB if no contraindications. FICB really does help thus subgroup of patients (elderly with hip fracture). I've been sedating elderly patients with hip fractures for two decades with propofol prior to the SAB and positioning. I usually give 30-40 mg IV x 1 which results in excellent sedation.

There is debate about the superiority of SAB with low dose propofol sedation being better in preserving cognitive function and decreasing the incidence of POCD.

 

[BLADEMDA]

• Exposure to general anaesthesia could increase the risk of dementia
  www.sciencedaily.com/releases/2013/06/130601133925.htm
  
  Jun 1, 2013 - Exposure to general anaesthesia increases the risk of dementia in theelderly by 35 percent, says new research. ... Featured Research. from universities,journals, and other organizations ...

• No link between anesthesia, dementia in elderly -- ScienceDaily
  www.sciencedaily.com/releases/2013/05/130501090720.htm
  
  May 1, 2013 - from universities, journals, and other organizations .... Exposure to General Anaesthesia Could Increase the Risk of Dementia in Elderly by 35 ...

 

[Colba55o]

Thanks for the comments! We didn't do any Fascia Iliaca blocks in residency but it seems like a popular technique. Do surgeons complain about the risk of falls post op from quadriceps weakness?

For those that do SAB with propofol are you generally doing what pgg does with the broken side up and using isobaric bupi? I have been doing them with the broken side down which I'm sure is why the propofol bolus I give often wears off by the time we turn position and Ive prepped and draped. By then I can sometimes ask the nurse to give another bolus but I'm sterile and can't manage the airway while doing the spinal at the same time.

Also are the patients actually awake when you are doing the SAB? Awake so that they could tell you if they are feeling a parasthesia?

 

[risnwb]

I use Ketamine as well. 25 mcg usually suffices. Keeps them nice and still and sedated without respiratory depression. I usually use .5% isobaric bupi if they are old and/or have cardiac issues, somewhere in the range of 2-3 mls. Usually fracture side down, even with the isobaric... I've had attendings say it actually hurts less that way... Unclear if this is valid.

 

[nap$ter]

Thanks for the comments! We didn't do any Fascia Iliaca blocks in residency but it seems like a popular technique. Do surgeons complain about the risk of falls post op from quadriceps weakness?

no.

a. these aren't like knee replacements; the patients aren't always marched out of bed by PT as rigorously on POD 1 - often the procedure is semi-palliative.
b. the risk of falls after FNB's or FICB's is a whole other topic rife with controversy - i don't believe it is a valid concern as long as your facility/staff is accustomed to taking care of patients with those blocks. falls occur when communication is poor.

 

[Planktonmd]

I do most of these hip ORIFs under TIVA with LMA and avoid inhaled agents hoping they will not be more confused after the surgery, and I only do fascia iliaca block if they are having too much pain post-op (most don't).
Occasionally I do a spinal on patients with mild dementia whom I feel strongly that any GA is going to tip them over, and for that It's Ketamine 25-50 mg turn on the side (it makes no difference which side) and hyperbaric spinal.
Interestingly Ketamine does not appear to affect their mental state for too long as GA would.

 

[seinfeld]

Are far as peoples concerns about sedation and spinal I would remind people that when a septic patient presents with Altered Mental Status and no clear source of infection they get an LP.

If spinal is an option i do the prop bolus and then 22g or 25 g whatever does the job

 

[shift_roro]

Those using ketamine, are you also using midaz to prevent reemergence phenomenon? If so, before or after the spinal and how much?

 

[psychbender]

At the low-dose range, ketamine's psychomimetic properties appear to be minimal. I used to use ketamine all the time for sedation for epidurals and peripheral nerve catheters in young multi-extremity trauma patients in whom positioning was quite painful. Versed was not always added, and some of these patients were on 10-40mg/hr ketamine infusions on the ward without benzos, tolerating it just fine. I no longer care for that population, but still sometimes use ketamine for situations like those presented, and rarely include versed, provided my ketamine dose is low. Thusfar, I have yet to see any significant emergence phenomenon with this practice.

 

[Planktonmd]

Those using ketamine, are you also using midaz to prevent reemergence phenomenon? If so, before or after the spinal and how much?

I don't give Midazolam to the elderly...

 

[BobBarker]

Me enjoy this discussion. Me do no neuraxial except OB in residency.

 

[Dawkter]

To rehash this topic- are most people who are performing spinals on these elderly hip fracture patients doing it in the lateral position with ketamine + fentanyl (I rarely give midazolam as these patients are > 80 years old)?

I have been doing spinals for these but can barely get the patient to cooperate for more than a few minutes... am considering transitioning to GA for these cases.

 

[CaliCatheter]

My routine on these is... Have my tray setup with the 22ga....bring head of bed as high as pt can tolerate.

Titrating with a few ccs of prop and precedex. Have my assistant sit the pt up. With one arm pushing on pt spine I prep with other and dart my 22ga in until the champagne tap...in my experience puts have tolerated this pretty well. On those that I am unable to sit, I will do lateral with broken side up

 

[facted]

To rehash this topic- are most people who are performing spinals on these elderly hip fracture patients doing it in the lateral position with ketamine + fentanyl (I rarely give midazolam as these patients are > 80 years old)?

I have been doing spinals for these but can barely get the patient to cooperate for more than a few minutes... am considering transitioning to GA for these cases.

0.5mg midaz, 20-30mg ketamine. Broken hip side down. Isobaric spinal with a 22 and usually no other sedation. That 30 of ketamine usually gets them through the next hr...

Only do GA for pt refusal or anticoagulation.

 

[Hoya11]

Can anyone offer advice on smoothly doing spinals or even epidurals on hip fracture patients that are in too much pain to move let alone position themselves?

I know regional provides better pain control, less DVTs, transfusions etc but I find it such a struggle to try to do spinals on these patients. Some of my colleagues say they give a propofol bolus before turning the patient into position, but I have found this either leads to desaturation or the patient becoming squirrely or disoriented just when I'm trying to put a needle in their back. Plus since its often done on the hospital bed before moving them onto the table, the positioning is suboptimal, the assistant and I straining our backs since the beds are wider. For those of you that do the propofol bolus thing are your patients fully awake when you begin to do the spinal?

Isn't it risky doing a spinal in a sedated patient? I know people to caudals and epidurals in peds under GA but I worry whether its worth the risk in this population. Id rather get a transfusion or a DVT rather than permanent nerve damage. Do you find that even in a sedated state the patient is able to get into a good tight curled fetal position or is the assitant doing most of the work?

put them to sleep on the bed. LMA. Doesnt need a block. End up giving 50-100 of fent. I give sevo to old people in this relatively clean anesthetic (no benzos, minimal opiate)

 

[deleted697535]

Femoral nerve block with half lido half bupi, then you can crank them in half, paramedian spinal.
1cc or 2 of propofol if you need to is almost always tolerated ok

I try to stay away from.midaz ketamine in this population unless I'm stuck.
Once the nurses are on board a femoral nerve block takes maybe 5 extra mins

 

[SonnyBoy]

For your elderly demented NH residents, do you routinely obtain an echo to rule out significant AS prior to neuraxial?

 

[caligas]

I also prefer LMA generals for these cases.

 

[Dawkter]

0.5mg midaz, 20-30mg ketamine. Broken hip side down. Isobaric spinal with a 22 and usually no other sedation. That 30 of ketamine usually gets them through the next hr...

Only do GA for pt refusal or anticoagulation.

Is it broken side down or broken side up? Keep hearing conflicting things but it seems like laying on the fractured side would be painful.

Thanks for the tips!

 

[deleted162650]

Is it broken side down or broken side up? Keep hearing conflicting things but it seems like laying on the fractured side would be painful.

Thanks for the tips!

I recommend trying both and forming your own opinion on the matter. Fx up for me.

 

[Shimmy8]

LMA no block unless I’m really worried about respiratory status. Half of these are sorta palliative anyway.

 

[dannyboy1]

I use a little ketamine to get them on the OR table and placed in the operative position. Then I do the spinal (isobaric bupi). If for some reason I can’t get the spinal then quickly supinate and intubate. Usually use the 22g for these patients as well

 

[jeesapeesa]

on average 1 of these cases every time i'm on call. 50-100 mcg fentanyl, intubate on bed, move to OR table/position. no block. wake up comfortable.

 

[Pluto201]

I do LMA then move them to OR table. Use minimal inhalational I can get away with.


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[jope]

My usual formula for hip #s that works 90% of the time unless I can't get the spinal in.

1) O2 by nasal prongs/mask
2) ketamine 0.5 mg/kg iv push
3) Lateral position with # up and do my best to get fetal position
4) 2-2.5 cc 0.5% bupivicaine + 15 mcg fentanyl. I prefer isobaric bupivicaine so that it stays at the level of the injection and is likely less affected by gravity than hyperbaric.
5) prop/remi infusion for sedation

 

[deleted162650]

4) 2-2.5 cc 0.5% bupivicaine + 15 mcg fentanyl.

That's a big F'in spinal dose for what is usually a short case.

5) prop/remi infusion for sedation

What's the Remi doing for you here??

 

[woopedazz]

Our hospital does FI in the ER on arrival - performed by ER physicians under US, most of the time works well.
Optimise patient (including TTE if indicated).
Put in a second FI in holding bay/prep room if they've been waiting a while - most of ours are done ~12-18 hours post-admit in office hours and post-optimisation.
Now they're numb for movement + hopefully most of the procedure (sans skin cut) --> straight onto the table for GA, or, roll lateral for spinal (# side up, plain) then onto the table. Depending on what is more appropriate for the patient.
If neuraxial --> very light sedation with propofol only.
If GA --> LMA + usual stuff.

 

[jope]

That's a big F'in spinal dose for what is usually a short case.



What's the Remi doing for you here??

I know it's usually a short case but I would prefer to not have to worry about converting to a GA if the case runs long. The remi just lets me use less PPF. Patients seem to sedate a bit easier over just PPF alone but it likely doesn't matter.

 

[Psai]

I know it's usually a short case but I would prefer to not have to worry about converting to a GA if the case runs long. The remi just lets me use less PPF. Patients seem to sedate a bit easier over just PPF alone but it likely doesn't matter.

??? People sedated just fine with propofol only and they probably don't even need that

 

[Arch Guillotti]

For your elderly demented NH residents, do you routinely obtain an echo to rule out significant AS prior to neuraxial?

No.

 

[Arch Guillotti]

That's a big F'in spinal dose for what is usually a short case.

You want to give them less than 10 mg?

I would give 12.5-15 mg for every single one!

 

[deleted162650]

I give 1.5mL isobaric 0.5% bupi plain (7.5mg) for all elective total joints. No IT opioid. Our surgeons aren’t speed demons either. 2.5-3hr cases on average. An IMN or Hemi for a hip Fx are considerably quicker.

 

[PainDrain]

I give 1.5mL isobaric 0.5% bupi plain (7.5mg) for all elective total joints. No IT opioid. Our surgeons aren’t speed demons either. 2.5-3hr cases on average. An IMN or Hemi for a hip Fx are considerably quicker.

This dose will typically give you 3 hours of dense block because it’s isobaric and it behaves differently than heavy bupi. I love the iso spinal. It’s almost cheating it’s so easy.

 

[jope]

For your elderly demented NH residents, do you routinely obtain an echo to rule out significant AS prior to neuraxial?

Ausculation is good enough. If you hear a harsh SEM, then maybe consider it if you can't see it well on bedside TTE.

 

[pgg]

Bedside TTE is a skill worth picking up. But like @jope says, if you can't hear the AS murmur from across the room, it's not bad enough to kill them with an isobaric spinal.

 

[UscGhost]

Keep it simple

1. 20-40mg propofol plus 20mg ketamine to position lateral
2. Spinal with 5-7.5 mg isobaric bupiv spinal
3. Concerns of undetected AS are way overblown. Isobarics dont drop pressure much and treat with neosyn prn
4. 22g spinal needle
5. Change to LMA if you cant get the spinal
6. FI block after

 

[Urzuz]

Keep it simple

1. 20-40mg propofol plus 20mg ketamine to position lateral
2. Spinal with 5-7.5 mg isobaric bupiv spinal
3. Concerns of undetected AS are way overblown. Isobarics dont drop pressure much and treat with neosyn prn
4. 22g spinal needle
5. Change to LMA if you cant get the spinal
6. FI block after

Yeah, simple...if you ignore every step you listed out except #5. I don’t want to see what your anesthetic plans look like when you’re feeling particularly fancy.

I do these cases with a preop fascia iliaca block plus an LMA GA with ~0.5 MAC of gas.

 

[ScarfTheVerb]

LMA and 50-100mcg of fentanyl for me. These patients have very little pain postop.

 

[UscGhost]

Patients do better with spinals...even the surgeons are asking for them now. You can see the difference immediately in pacu.

ncbi.nlm.nih.gov/pmc/articles/PMC5490182/


Twenty retrospective observational and three prospective randomised controlled studies were included. There was no difference in the 30-day mortality [OR 0.99; 95% CI (0.94 to 1.04), p = 0.60] between the general and the neuraxial anaesthesia group. The in-hospital mortality [OR 0.85; 95% CI (0.76 to 0.95), p = 0.004] and the length of hospital stay were significantly shorter in the neuraxial anaesthesia group [MD -0.26; 95% CI (−0.36 to −0.17); p < 0.00001].

 

[nimbus]

The thing is prop40+ketamine20 is a GA in a lot of hip patients.

I don’t think you can compare GA vs Spinal unless you tightly control how each are conducted.

I do a lot of these with FICB+GA/lma with propofol+sevo only. No other agents i.e. no benzos, opioids, or ketamine. And they are awake and chatty 5-10min after arrival in pacu.

 

[dhb]

I don’t think you can compare GA vs Spinal unless you tightly control how each are conducted.

And in which patient: most people don't do a spinal if the patient is severely demented.

 

[facted]

Is it broken side down or broken side up? Keep hearing conflicting things but it seems like laying on the fractured side would be painful.

Thanks for the tips!

Fracture down is less painful from multiple surgeons I've spoken to about it. Seems that having a broken bone blowing in the wind and moving all around isn't so great. But, I do give a little midaz and 20-30mg of ketamine first, so it's kinda like "if a tree falls in the forest..."

 

[facted]

My usual formula for hip #s that works 90% of the time unless I can't get the spinal in.

1) O2 by nasal prongs/mask
2) ketamine 0.5 mg/kg iv push
3) Lateral position with # up and do my best to get fetal position
4) 2-2.5 cc 0.5% bupivicaine + 15 mcg fentanyl. I prefer isobaric bupivicaine so that it stays at the level of the injection and is likely less affected by gravity than hyperbaric.
5) prop/remi infusion for sedation

I do similar, but less ketamine and rarely give prop for sedation. Have you tried with less ketamine and without sedation? I usually find that 20-30mg of ketamine is enough for the spinal and can get you ~ 1 hr of "sedation" for the case as well.

 

[facted]

Keep it simple

1. 20-40mg propofol plus 20mg ketamine to position lateral
2. Spinal with 5-7.5 mg isobaric bupiv spinal
3. Concerns of undetected AS are way overblown. Isobarics dont drop pressure much and treat with neosyn prn
4. 22g spinal needle
5. Change to LMA if you cant get the spinal
6. FI block after

Very similar, but I skip the prop. I've had partners run into trouble with that little bit of propofol while positioning and not monitoring as carefully while you're placing the spinal (obviously more of an issue if you're working alone). Agree with the isobaric, usually at 1.5-2ml. Haven't found a need for a block. Older patients really do have less pain and post-op pain hasn't been an issue in my patients.