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.
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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