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Surgical treatment of proximal femoral fractures in high-risk geriatric patients under peripheral regional anesthesia

A prospective feasibility study

Operative Versorgung proximaler Femurfrakturen bei geriatrischen Hochrisikopatienten in peripherer Regionalanästhesie

Eine prospektive Machbarkeitsstudie

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Abstract

Background and objective

Due to changing demographics geriatric patients with multiple comorbidities and proximal femoral fractures are an increasing patient population. In these patient groups, peripheral regional anesthesia could become increasingly more important besides established procedures, such as neuraxial or general anesthesia. The aim of this single center feasibility study was to evaluate a combined blockade technique of the lumbosacral plexus for three predefined subgroups depending on the type of hip fracture.

Methods

We used a unilateral double injection three-step technique to block the sacral (parasacral block) and lumbar plexus (anterior quadratus lumborum and psoas compartment block, n = 78). The blockade was performed both under ultrasound guidance and simultaneous nerve stimulation and 20 ml ropivacaine 0.375% was injected at each of the 3 injection sites (total dose 225 mg).

Results

In 42% of cases the surgery was opioid-free (n = 33). In 5 patients a conversion to general anesthesia (insertion of a laryngeal mask and pressure-controlled or pressure-supported ventilation) was necessary (6%). The overall success rate of combination anesthesia (peripheral nerve blocks with supplemental sedative (propofol 1–2 mg/kg*h) or analgesic (incremental doses of 5 µg sufentanil) medication) was 94%, regardless of fracture type and surgical treatment.

Conclusion

The combined anesthetic technique presented in this study enables surgical treatment of proximal femoral fractures. The associated effort and requirement for expert knowledge in regional anesthesia indicates that this method should be considered especially in cases with high anesthetic risk, suitable sonoanatomy, and non-compromised coagulation.

Zusammenfassung

Hintergrund und Ziele

Geriatrische Patienten mit multiplen Komorbiditäten und proximalen Femurfrakturen stellen aufgrund der demographischen Entwicklung eine wachsende Patientenpopulation dar. Die potenzielle Vermeidung von intraoperativen Hypotonien oder eines postoperativen Delirs könnte zu einer zunehmenden Bedeutung peripherer Nervenblockaden in Ergänzung etablierter Anästhesieverfahren führen. Ziel dieser monozentrischen prospektiven Machbarkeitsstudie war die Evaluierung einer kombinierten Blockadetechnik des lumbosakralen Plexus für drei vordefinierte Subgruppen in Abhängigkeit vom Frakturtyp.

Material und Methoden

Wir führten eine einseitige kombinierte Blockade des Plexus sacralis (parasakraler Block) und des Plexus lumbalis (anteriorer Quadratus lumborum und Psoas-compartment-Block) unter Ultraschallkontrolle und gleichzeitiger Nervenstimulation durch (n = 78). An jeder der 3 Injektionsstellen wurden 20 ml Ropivacain 0,375 % injiziert (Gesamtdosis 225 mg).

Ergebnisse

In 42 % der Fälle konnte die operative Versorgung ohne zusätzliche Opioidgaben erfolgen (n = 33). Bei 5 Patienten war ein Verfahrenswechsel (Einsetzen einer Larynxmaske und druckunterstützte Beatmung) notwendig (6 %). Die Gesamterfolgsrate als Kombinationsanästhesie mit peripheren Nervenblockaden und sedierender (Propofol 1–2 mg/kg*h) oder analgetischer Komedikation (fraktionierte Dosen von 5 µg Sufentanil) betrug 94 %, unabhängig vom Frakturtyp und der Art der chirurgischen Versorgung.

Schlussfolgerung

Die in dieser Studie vorgestellte kombinierte Anästhesietechnik ermöglicht die chirurgische Behandlung von proximalen Femurfrakturen. Die erforderliche regionalanästhesiologische Expertise für die paravertebralen Injektionen impliziert, dass die Methode insbesondere in Fällen mit hohem Anästhesierisiko, geeigneter Sonoanatomie und nicht kritisch eingeschränkter Gerinnungssituation erwogen werden sollte.

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Abbreviations

ASA PS:

American Society of Anesthesiologists physical status

CI:

Confidence interval

ICD-10:

International Classification of Diseases 10th Revision

IQR:

Interquartile range

IQTIG:

Institute for Quality Assurance and Transparency in Health Care

KDIGO:

Kidney Disease: Improving Global Outcomes

MAP:

Mean arterial pressure

OAK:

Oral anticoagulants

PCB:

Psoas compartment block

PFNA:

Proximal femoral nail antirotation

PPSB:

Prothrombin complex concentrate

QLB:

Quadratus lumborum block

SG:

Subgroup

UTI:

Urinary tract infection

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Acknowledgements

Editorial assistance, in the form of language editing and correction, was provided by XpertScientific Editing and Consulting Services. Furthermore, we would like to thank Hiltrud Niggemann (www.p-wert.de) for her help with the statistical analysis.

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Authors and Affiliations

  1. Department of Anesthesiology and Intensive Care, Asklepios Medical Center Schwedt/Oder, Am Klinikum 1, 16303, Schwedt, Germany

    Ronald Seidel

  2. Department of Anesthesiology, Helios Medical Center Schwerin, Wismarsche Straße 393–7, 19049, Schwerin, Germany

    Eduard Barbakow

  3. Department for Trauma and Reconstructive Surgery, Helios Medical Center Schwerin, Wismarsche Straße 393–7, 19049, Schwerin, Germany

    Stefan Schulz-Drost

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Correspondence to Ronald Seidel.

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Conflict of interest

R. Seidel reports grants from Helios Center for Research and Innovation, during the conduct of the study; personal fees from USRA Medical Education, outside the submitted work. E. Barbakow reports grants from Helios Center for Research and Innovation, during the conduct of the study; personal fees from USRA Medical Education, outside the submitted work; and S. Schulz-Drost reports grants from Helios Center for Research and Innovation, during the conduct of the study.

The study was approved by the Ethics Committee of the University of Rostock, Germany (A 2018 0237) and is registered on ClinicalTrials.gov (identifier: NCT 04005404). Written informed consent was obtained from patients or, in accordance with the Ethics Committee, from an authorized legal representative.

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Seidel, R., Barbakow, E. & Schulz-Drost, S. Surgical treatment of proximal femoral fractures in high-risk geriatric patients under peripheral regional anesthesia. Anaesthesist 70, 1022–1030 (2021). https://doi.org/10.1007/s00101-021-00935-6

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  • DOI: https://doi.org/10.1007/s00101-021-00935-6

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