8. Regional / Trauma Flashcards
Q1 — Nerve block for shoulder surgery
a) List the specific nerves that need to be blocked to achieve
effective analgesia for shoulder surgery.
The shoulder area is supplied by both the cervical and brachial plexus as
follows:
Cervical plexus:
● Transverse cervical nerve.
● Supraclavicular nerve.
Brachial plexus:
● Upper lateral cutaneous branch of the axillary nerve.
● Medial cutaneous nerve of the arm.
● Intercostobrachial nerve.
● Suprascapular nerve.
b) Name any six possible complications of an interscalene block.
● Subarachnoid/epidural injection.
● Stellate ganglion block.
● Pneumothorax.
● Phrenic nerve palsy — ipsilateral hemidiaphragmatic paralysis.
● Horner’s syndrome.
● Local anaesthetic toxicity.
● Accidental intravenous injection.
c) What positioning is needed for shoulder surgery?
The deck chair (modified sitting position) is most commonly used for
shoulder surgeries.
d) List any three complications of positioning for shoulder surgery.
● Hypotension due to venous pooling in the extremities.
● Intraoperative cerebral ischaemia.
● Activation of the Bezold-Jarisch reflex leading to profound
bradycardia, hypotension and even cardiac arrest.
● Neurological injuries.
e) What postoperative advice would you give to a patient who has
received an interscalene block
1 After an interscalene block, your arm may remain weak for up to 24
hours.
2 ● As the numbness wears off, it is normal to feel pins and needles in the
hand.
3 ● Take regular analgesics postoperatively to avoid sudden intense pain
once the block wears off.
4 ● Protect and support your arm, preferably in a sling.
5 ● Avoid handling machinery, driving, and contact with very hot or cold
objects.
6 ● If the numbness lasts for more than 24 hours or you get breathless,
ring the hospital number provided
Q2 — Regional block in hip fractures
An 80-year-old woman is admitted to hospital having sustained a proximal
femoral (neck of femur) fracture in a fall.
a) How would you optimise this patient’s pain preoperatively?
.
● Assessment of pain by recording pain scores should be done on
admission to the accident and emergency department, after 30
minutes and then regularly after starting regular analgesia.
● Immobilisation of the injured leg.
● Simple analgesia with paracetamol (avoid NSAIDs).
● Multimodal analgesia with sparing use of opioids.
● Regional nerve blocks.
b) What is the nerve supply of the skin overlying the hip joint?
● Cluneal nerves — superior, medial and inferior.
● Anterior cutaneous branch of the femoral nerve.
● Cutaneous branch of the obturator nerve.
● Lateral cutaneous nerve of the thigh.
● Lateral cutaneous branch of the iliohypogastric nerve.
c) What regional nerve blocks can be used to provide
preoperative analgesia?
● Femoral nerve block.
● Fascia iliaca block.
● Lateral cutaneous nerve of the thigh block.
● Psoas block.
d) What nerves are blocked by the fascia iliaca block?
● Lateral femoral cutaneous nerve.
● Femoral nerve.
● Obturator nerve.
e) List the scoring systems that can be used to predict 30-day
mortality in this patient.
● Nottingham Hip Fracture Score.
● Estimation of Physiological Ability and Surgical Stress (E-PASS).
● O-POSSUM
(Physiological and Operative Severity Score for the
enUmeration of Mortality and morbidity modified for orthopaedic
usage).
f) List the AAGBI recommendations regarding unacceptable
reasons for delaying surgery
● Lack of facilities or operating theatre space.
● Awaiting echocardiography.
● Unavailable surgical expertise.
● Minor electrolyte abnormalities.
Key Points
1 Hip fracture is a major and increasing concern for public health.
2 Timely hip fracture repair surgery is associated with lower morbidity and mortality.
3 There is little evidence to suggest that general or regional anaesthesia is superior; the conduct of each should account for a patient’s physiological limitations.
4 A quarter of patients with hip fracture experience postoperative delirium.
4 Hypotension is associated with an increased risk of mortality; in many cases, it can be avoided by minimising the doses of anaesthetic agents.
Intro
comorb
30 day mortality changes
BPT in ireland
Disorders of cognition are common in patients with hip fracture, with 30% having severe cognitive impairment before surgery.
Although hip fracture remains the commonest cause of death after an accidental injury,
30 day mortality increased from 2007 to 18
Increased attention paid to processes and outcomes; the introduction of clinical guidelines; and, in England and Ireland, the introduction of Best Practice Tariffs (BPTs) for hip fracture care
1 Admission to an acute orthopaedic ward (or operating theatre) within 4 h of presentation
Surgery within 48 h of admission and within normal working hours
Does not develop a new Grade 2 or higher pressure ulcer during admission
Reviewed by a geriatrician at any point during admission
Bone health assessment
Specialist falls assessment
Varying focus of evidence / guidelines
More recent guidelines by the Association of Anaesthetists and Fragility Fracture Network
POCD / delirium
specifies postoperative screening for delirium using the 4AT
delirium and long-term complications, such as loss of function, cognitive impairment and increasing dependency, have profoundly negative impacts on patients’ lives
Evidence-based anaesthesia for hip fracture repairp
Spinal GA
that there is no convincing evidence that either regional or GA is superior.
Cochrane review concluded that the only benefit to regional anaesthesia
is a lower rate of venous thromboembolism
in the absence of pharmacological thromboprophylaxis.
variations in practice within different modes of anaesthesia accounts for some of the difficulty in generating evidence to guide practice
It is also possible that anaesthesia has less of an impact than receiving timely surgery, high-quality orthogeriatric care and appropriate rehabilitation
Although there is little evidence to favour either mode of anaesthesia, accumulating evidence suggests that the aims and techniques of anaesthesia (of either mode) are important in hip fracture repair.
Intraoperative surgical and anaesthetic roles to reduce the risk of BCIS. Reproduced from the Association of Anaesthetists/BOA/BGS guideline.
Evidence based Anaesthesia
Proceed with surgery?
Proceeding with anaesthesia and surgery
Patients may have been told they are ‘not fit’ for elective hip surgery.
the risk of proceeding must be weighed against the risk of adopting a non-operative approach
risks of not operating are even higher, and non-operative management involves several weeks of painful immobilisation
NHFD data, Johansen and colleagues
48.6% of patients with hip fracture who did not undergo surgical repair died in a hospital, compared with 6.6% of patients who underwent surgery.
provides effective analgesia, we suggest that it is reasonable to proceed even when the procedure is deemed to be palliative, unless the patient is felt to be likely to die imminentl
Enabling timely hip fracture repair
Enabling timely hip fracture repair
Irish Hip Fracture Database adopting a standard of 48 h
Fragility Fracture Network.
sing NHFD data, Sayers and colleagues demonstrated a 9.4% relative increase in 30-day mortality risk when hip fracture repair was undertaken >24 h after hospital admission
mongst patients with mild-to-moderate cognitive impairment, delaying surgery for more than 1 day increases the risk of delirium two-fold.
(HIP ATTACK) study, a large international RCT comparing complication rates when ‘accelerated’ hip fracture repair was undertaken (median: 6 h from diagnosis) with standard care (median: 24 h),
However, the risk of delirium and the times to mobilisation and discharge were all significantly lower in the ‘accelerated’ group
Avoiding hypotension
The ASAP-2 study used NHFD outcome data to compare anaesthetic techniques as recorded in the ASAP.
No mortality benefit was found to either spinal anaesthesia or GA, but a statistically significant increase in 5- and 30-day mortality was associated with incremental decreases in the lowest recorded MAP.
Bone cement implantation syndrome (BCIS) is an important cause of cardiovascular (and respiratory) collapse during cemented hemiarthroplasty and total hip replacement, and to a lesser extent in any procedure involving instrumentation of the femoral canal (e.g. femoral nail).
RF
male sex,
the use of diuretics,
significant cardiopulmonary disease
and increasing age
Intraoperative surgical and anaesthetic roles to reduce the risk of BCIS. Reproduced from the Association of Anaesthetists/BOA/BGS guideline.
Conduct of surgery
1 Ask the anaesthetist to confirm that he/she has heard your instruction to the theatre team that you are about to prepare the femoral canal for cement and prosthesis insertion.
2 Carefully prepare, wash, and dry the femoral canal. Use of a pressurised lavage system is recommended to clean the endosteal bone of fat and marrow contents.
3 Use a distal suction catheter on top of an intramedullary plug. Insert the cement from a gun in retrograde fashion on top of the plug and pull the catheter out as soon as it is blocked with cement.
4 Do not use excessive manual pressurisation or pressurisation devices in patients at higher risk of cardiovascular events.
_____________________________________________
Conduct of anaesthesia
1 Ensure that the patient is adequately hydrated before induction of and during anaesthesia.
2 Maintain vigilance for possible cardiovascular events once the femoral head is removed and the surgeon has verbally indicated his/her intent to instrument the femoral canal.
3 Confirm to the surgeon that you are aware of preparation of the femoral canal for cement and prosthesis insertion.
4 Aim to maintain the systolic blood pressure within 20% of preinduction values throughout surgery, using vasopressors and/or fluids. Invasive blood pressure monitoring is indicated for patients at higher risk.
5 Be ready to give vasopressors, e.g. metaraminol/adrenaline in case of cardiovascular collapse.
Peripheral nerve block
Peripheral nerve block
The fascia iliaca compartment block (FICB), femoral nerve block and 3-in-1 block provide effective but incomplete analgesia in patients with hip fracture
hip joint arises from both the lumbar and sacral plexuses.
(LCNT) should be blocked for surgery, as it supplies the skin that is incised, although additional local anaesthetic infiltration is required if a posterior surgical approach
Association of Anaesthetists advises that peripheral nerve blocks for hip fracture patients can be repeated after 6
FICB in the perioperative period even if it has been undertaken earlier, to reduce quadriceps femoris muscle spasm, facilitate positioning for anaesthesia and provide postoperative pain relief
Avoiding cognitive complications
Avoiding cognitive complications
1 Delirium affects a quarter of people with hip fracture
and is associated with increased rates of adverse outcomes,
including mortality and the need for residential or nursing care.
Timely hip fracture surgery appears to mitigate the risk of delirium,
f brain hypoperfusion attributable to hypotension may have a protective effect
Drugs and delirium,
including opioids and
drugs with central anticholinergic activity,
such as cyclizine, prochlorperazine and atropine
. A multidisciplinary ‘care bundle’ approach focused on the provision of FICB and the avoidance of long-acting opioids, antihistamines, antipsychotics and anticholinergics, maintained through staff education and continuous audit, appears to be effective in preventing delirium
Controversies
‘Delay’ vs ‘optimisation’
delaying surgery may be appropriate if effective optimisation is undertaken during this time.
- Anaemia and blood transfusion
target of 9 g dl−1 should be adopted for frailer patients
to 10 g dl−1 for patients with a history of ischaemic heart disease,
use of tranexamic acid.
Controversies
‘Delay’ vs ‘optimisation’
delaying surgery may be appropriate if effective optimisation is undertaken during this time.
- Anaemia and blood transfusion
target of 9 g dl−1 should be adopted for frailer patients
to 10 g dl−1 for patients with a history of ischaemic heart disease,
use of tranexamic acid. - Undiagnosed cardiac murmur
However, surgery should not be delayed pending the results of echocardiography for undiagnosed murmurs; anaesthesia should instead proceed with invasive blood pressure monitoring and particular attention paid to maintaining cardiovascular stability through the use of lower doses of anaesthesia, i.v. fluids and vasoactive drugs as appropriate. - Anti-platelets, anticoagulants and spinal anaesthesia
ragmatic approach to anticoagulation when spinal anaesthesia is deemed superior to GA (e.g. severe chest disease) - Single antiplatelet therapy, including clopidogrel, is not a contraindication to spinal anaesthesia. Spinal anaesthesia may be appropriate for patients taking dual antiplatelet therapy for who are unsuitable for GA, on a risk/benefit basis
- )
For patients taking vitamin K antagonists, spinal anaesthesia can be undertaken once the international normalised ratio (INR) is ≤1.5.
if
INR of >1.5 should receive an initial dose of vitamin K as soon as possible (i.e. in the emergency department), with further vitamin K or prothrombin complex concentrate if the INR remains >1.5 after 4–6 h. - )
Direct-acting oral anticoagulant (DOAC) activity cannot be reliably assessed using standard coagulation tests. However, unless the patient has severe renal dysfunction (i.e. creatinine clearance <30 ml min
provided after two half-lives have elapsed.
last dose of DOAC should therefore be confirmed, and spinal anaesthesia can usually be undertaken on the following day
Conduct of spinal
ASAP adopted a standard dose of bupivacaine ≤10 mg for use in spinal anaesthesia, and stated that, if used, intrathecal opioids should be limited to fentanyl
e ASAP found that a median dose of 2.5 ml bupivacaine 0.5% (12.5 mg) was used,
bupivacaine 4 mg plus fentanyl 20 μg, diluted with saline 0.9% to a total volume of 2 ml (described as ‘mini-dose’ spinal), and 2 ml glucose-free bupivacaine 0.5% (10 mg) without opioid are sufficient for hip fracture surgeries lasting up to 110 min after injection, with fewer interventions for hypotension required in the mini-dose group.
hese findings suggest that lower doses are both practical and desirable, particularly when used in combination with FICB,
analgesia in the event that surgery is prolonged
Conduct of spinal
ASAP adopted a standard dose of bupivacaine ≤10 mg for use in spinal anaesthesia, and stated that, if used, intrathecal opioids should be limited to fentanyl
e ASAP found that a median dose of 2.5 ml bupivacaine 0.5% (12.5 mg) was used,
bupivacaine 4 mg plus fentanyl 20 μg, diluted with saline 0.9% to a total volume of 2 ml (described as ‘mini-dose’ spinal), and 2 ml glucose-free bupivacaine 0.5% (10 mg) without opioid are sufficient for hip fracture surgeries lasting up to 110 min after injection, with fewer interventions for hypotension required in the mini-dose group.
hese findings suggest that lower doses are both practical and desirable, particularly when used in combination with FICB,
analgesia in the event that surgery is prolonged
ocedures requiring fracture reduction before incision may require the anaesthetic to last substantially longer than the operating time itself
he predicted operating time, and the time taken to position the patient and prepare the surgical field, should be communicated effectively during the ‘team brief’. When surgery is unexpectedly prolonged, additional infiltration of local anaesthetic, cautious administration of systemic analgesics and conversion to GA are all acceptable strategies for maintaining the patient’s comfort
sedation
ver sedation in patients with hip fracture is common, and the role of sedative and analgesic medications in postoperative delirium is well described. In one comparison of ‘lighter’ vs ‘heavier’ sedation (assessed clinically) during hip fracture repair, heavier sedation doubled the risk of postoperative delirium in patients with a low burden of comorbidity,
many patients fall asleep once spinal anaesthesia has been established, sedative drugs can be avoided in most cases. We therefore suggest that sedatives should be used with caution and limited to short-acting, titratable agents; propofol by target-controlled infusion is ideal
Conduct of GA
The aims of GA are similar to those of spinal anaesthesia: hypotension and deliriant drugs should be avoided if possible, and anaesthetic doses should be sympathetic to the limited physiological reserve of patients with hip fracture. Strategies to optimise anaesthetic dose include depth of anaesthesia monitoring, using age-adjusted minimum alveolar concentration values for volatile anaesthesia, and carefully titrating induction agents against clinical and EEG-based assessments of anaesthetic depth.
Peripheral nerve blocks help to minimise the required dose of both anaesthetic agents and opioids by reducing nociception during surgery and providing effective postoperative analgesia, and should be performed before or shortly after the induction of anaesthesia.
Maintaining spontaneous respiration minimises the risk of atelectasis, barotrauma and any hypotension associated with positive-pressure ventilation
inhalational or titrated i.v. induction, either manually or by using a target-controlled infusion
There is an argument for adopting a low threshold for tracheal intubation. This can be achieved in combination with spontaneous breathing by using deep inhalational induction or topical anaesthesia of the airway.
n is deemed to be not required, using a second-generation supraglottic airway that provides additional protection against aspiration is an appropriate approach.
Postoperative recovery
hip fracture should receive high-dependency care after surgery, as would now routinely be the case for patients with a similar predicted mortality risk after emergency abdominal surgery.
Adopting this approach on a universal basis would require resources that, at present, are unavailable in many healthcare systems
ctors in the critical care unit (e.g. monitors, alarms and frequent night-time interruptions), which may make delirium more likely in susceptible patients
by-case for the management of specific reversible conditions, after risk assessment and in consultation with the multidisciplinary team.
management pathway, aiming for early remobilisation, rehabilitation and maintenance of the patient’s prior cognitive function
thogeriatricians, occupational therapists and physiotherapists is important, and postoperative screening for delirium as specified in the English BPT
naesthetists should be mindful of enabling postoperative recovery through their anaesthetic technique. To this end, there is an argument for providing anaesthesia in a consistent way on an institutional basis, so that those involved in recovery and rehabilitation after hip fracture are better able to anticipate patients’ postoperative needs.
Consent
Informed consent for hip fracture anaesthesia presents several challenges; cognitive impairment is commonplace and mental capacity may fluctuate. Patients may not always wish to engage in a comprehensive discussion of risk, as this may provoke unnecessary anxiety at an already stressful time.8 It is often appropriate to involve family members or other advocates in the consent process, and to establish how much the patient wishes to know at an early point in the discussion.
aterial risks’ (i.e. those important to the patient), being mindful of the specific complications associated with hip fracture surgery (e.g. the high rate of postoperative cognitive complications).28 Risk stratification tools, such as the Nottingham Hip Fracture Score, may be useful, including by providing a basis for reassurance in lower-risk cases.29
Patients should be offered a choice of the ‘reasonable options’ for their management (and the option to do nothing).28 This may involve a discussion of both general and spinal anaesthesia, and peripheral nerve blocks and sedation. Whilst patients should have a free choice, we suggest it is reasonable for the anaesthetist to explain what technique is usually provided at their institution, and the benefits that this may offer in terms of integrating peri- and postoperative care.
The patients’ experience of hip fracture anaesthesia has been studied, and qualitative research suggests that postoperative complications (e.g. pain, delirium and reduced mobility) are more important to patients than the mode of anaesthetic itself.
erhaps by measuring their experience of anaesthesia using tools, such as the Bauer questionnaire, and screening for complications, so that anaesthetists are able to optimise their practice accordingly.
a) Outline the basic physical principles involved in the formation
of an ultrasound image.
The formation of an ultrasound image is based upon
sound waves that are transmitted from,
and received by, an US transducer.
It utilises frequencies of 2-15MHz
(human hearing operates at 1-20kHz).
b) What is piezoelectrical activity and how is it utilised in
ultrasound?
Ultrasound transducers have piezoelectric properties:
● When current is applied across the crystal, it expands and contracts as
the polarity of the voltage changes. This produces a series of pressure
waves (sound waves).
● In reverse, when the sound wave returns, it squeezes and stretches
the crystal and generates a voltage change across its surface. This is
amplified and forms the receiving signal.
