Regional and hip fractures

[seinfeld]

What are people doing out there for hip fracture patients in terms of regional?

Do you fell femoral nerve block is adequate, are you placing catheters?

Anyone doing the entire operation under PNBs? if so what are you using.

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[2win]

What are people doing out there for hip fracture patients in terms of regional?

Do you fell femoral nerve block is adequate, are you placing catheters?

Anyone doing the entire operation under PNBs? if so what are you using.

"Do you fell femoral nerve block is adequate, are you placing catheters?"
No offense buddy - this is a joke, right? Just to confuse some students....

 

[seinfeld]

"Do you fell femoral nerve block is adequate, are you placing catheters?"
No offense buddy - this is a joke, right? Just to confuse some students....

So i assume you do a GA with no block for postop pain... right "buddy". Your tone is not appreciated.

Apparently you dont know about he increased incidence of POCD and are making no attempt to decrease its incidence.

Thanks DreamMachine for your imput, we are doing Lumbar plexus block, sciatic and spinal for a nonfractured, elective hip replacements, just wondered how much effort people were putting into regional in the acutely fractured patient. I have seen some articles talking about femoral nerve blocks and/or femoral nerve catheters being placed for the fracture hip. Actually some studies i found are having the ED placed the femoral nerve block.

 

[LongSnow]

I have heard of fascia illiaca blocks to augment analgesia for hip fractures, but not femoral nerve blocks. Seems either would pale in comparison to Lumbar plexus(LPB) or epidural, though. Never done a hip stricly under PNB. Lots of spinals, lots of generals, lots of generals + epidural, lots of generals + LPB. Seinfeld - could you post links to studies w/ femoral nerve block? thanks

 

[coprolalia]

The only way a femoral nerve block would be adequate is if you could "float" the catheter along the nerve sheath towards the lumbar plexus. Otherwise, there's no point in doing this block for a hip. It is good for knees, but not perfect as you still miss the posterior portion of the knee and everything distal to the patella unless you do a sciatic block too.

Lumbar plexus is the only way to go, but this can be a technically challenging (and therefore sometimes inadequate) block.

-copro

 

[2win]

So i assume you do a GA with no block for postop pain... right "buddy". Your tone is not appreciated.

Apparently you dont know about he increased incidence of POCD and are making no attempt to decrease its incidence.

Thanks DreamMachine for your imput, we are doing Lumbar plexus block, sciatic and spinal for a nonfractured, elective hip replacements, just wondered how much effort people were putting into regional in the acutely fractured patient. I have seen some articles talking about femoral nerve blocks and/or femoral nerve catheters being placed for the fracture hip. Actually some studies i found are having the ED placed the femoral nerve block.

Apologize if i offended you. It was not intended.
I thought that you are asking about femural nerve block just to confuse some students. I don't see any benefit for a femural nerve block for hip surgery. The lumbar plexus block - yes, it is useful. Spinal, CSE, Epidural - all are a YES.
"Apparently you dont know about he increased incidence of POCD and are making no attempt to decrease its incidence." - apparently I don't so please enlight me! What does it mean "increased incidence"? What about benzos and senile dementia? Narcotics and senile dementia?
Thank you,
2win

 

[Tuohy]

In contrast to other views on this thread, a femoral nerve block can be quite useful for an acute hip fracture. I have had many occassions to do a high volume single shot femoral nerve block (ie essentially a fascia iliaca block) and the patient has required 50-100 mcg of fentanyl for the entire case. The femoral nerve gives off articular branches to the hip joint. I am a regional fellowship-trained attending to give you some perspective.

 

[dhb]

Anyone doing the entire operation under PNBs? if so what are you using.

Yes i've done it under lumbar + sciatic block 20ml 0.75% ropivacaine each

 

[2win]

In contrast to other views on this thread, a femoral nerve block can be quite useful for an acute hip fracture. I have had many occassions to do a high volume single shot femoral nerve block (ie essentially a fascia iliaca block) and the patient has required 50-100 mcg of fentanyl for the entire case. The femoral nerve gives off articular branches to the hip joint. I am a regional fellowship-trained attending to give you some perspective.

Thank you -
http://www.anesthesia-analgesia.org/cgi/content/abstract/86/5/1039
http://clinicalevidence.bmj.com/ceweb/conditions/msd/1110/1110_I9.jsp

and this one
http://www.bestbets.org/bets/bet.php?id=1024
BUT - this isn't a femural nerve block.....and second this is good for post op or pre op pain control not for anesthesia.
I am really interested if you could post some more about your experience with fascia block for hip surgery - as a main technique.
2win

 

[Planktonmd]

In contrast to other views on this thread, a femoral nerve block can be quite useful for an acute hip fracture. I have had many occassions to do a high volume single shot femoral nerve block (ie essentially a fascia iliaca block) and the patient has required 50-100 mcg of fentanyl for the entire case. The femoral nerve gives off articular branches to the hip joint. I am a regional fellowship-trained attending to give you some perspective.

Agree.
I do a fascia iliaca block on 90 % of hip fractures and it works great.

 

[2win]

Agree.
I do a fascia iliaca block on 90 % of hip fractures and it works great.

Plankton - do you use the fascia iliac block for anesthesia or pain control?
2win

 

[thegasman]

So i assume you do a GA with no block for postop pain... right "buddy". Your tone is not appreciated.

Apparently you dont know about he increased incidence of POCD and are making no attempt to decrease its incidence.
.

What evidence is there that POCD is decreased with regional vs general anesthesia? It seems obvious that it would be, but I last time I looked at this, there was no difference in the studies.

 

[Planktonmd]

Plankton - do you use the fascia iliac block for anesthesia or pain control?
2win

For pain control and decreasing opioid requirement.

 

[seinfeld]

What evidence is there that POCD is decreased with regional vs general anesthesia? It seems obvious that it would be, but I last time I looked at this, there was no difference in the studies.

I agree, last i looked as well the POCD was not changed by GA vs epidural/spinal but i dont think they also looked at postop pain management and i cant remember whether intraop sedation was ruled out from the equation. If anyone can find studies or comment on that i would be all ears.

2win, i apologize for misinterpreting your connotations.

THanks everyone for the replies, Our orthopods are very open to suggestions for any improvements my group can make in pt satisfaction.

 

[2win]

I agree, last i looked as well the POCD was not changed by GA vs epidural/spinal but i dont think they also looked at postop pain management and i cant remember whether intraop sedation was ruled out from the equation. If anyone can find studies or comment on that i would be all ears.

2win, i apologize for misinterpreting your connotations.

THanks everyone for the replies, Our orthopods are very open to suggestions for any improvements my group can make in pt satisfaction.

Seinfeld - sometimes I get too rough...Sorry again for that.
I learned from your thread that it is useful for hip fracture to do a femoral nerve block ( really I didn't know that) and this is a gain for me.
Have a great Sunday!
2win

 

[huktonfonix]

Agree.
I do a fascia iliaca block on 90 % of hip fractures and it works great.

agreed, but if you do it as a straight femoral block, its not very useful especially if you do low dose with US.

 

[anesthesiadoc]

agreed, but if you do it as a straight femoral block, its not very useful especially if you do low dose with US.

Try it. 0.5% ropiv (+/- 1:200,000 epi) x 30ml. U/S guided femoral N. We've been doing it for the past 6 months on many of our hip fx and have been very pleased with the results.