Regional Anaesthesia in High Risk Elderly
Patients Undergoing Hip Surgery
Assoc Prof. Petchara Sundarathiti, MD
Ramathibodi Hospital, Mahidol University
Bangkok, Thailand
Regional Anaesthesia in High Risk Elderly
Patients Undergoing Hip Surgery
 Regional Anesthesia (RA) has long
been known to be benefit to patients
undergoing major orthopedic surgery.

Why Regional Anesthesia?
Benefits of Regional Anesthesia and Analgesia
1. RA provides more stable CV hemodynamics.
2. RAA provides superior pain relief in both intraoperative and
postoperative periods with a superior recovery profile and
better patient satisfaction.
3. RA placed preoperatively may provide preventive analgesia.
4. RA can avoid ET intubation & mechanical ventilation, leading
to less respiratory complications and less ICU demand .
5. RA attenuate stress responses and preserve immune response.
6. RAA reduces opioid-related complications.
7. Superior pain relief may reduce unplanned hospital admission.
Introduction
The majority of people suffering hip
fracture are elderly.
Most hip fractures are treated surgically
which required anaesthesia, and are
associated with a severe impact on
morbidity and mortality in the geriatric
population.
Introduction
Outcome is affected by multiple factors such as
pre-existing diseases, type of surgery and
anaesthesia, and quality of perioperative care.
Besides the GA and neuraxial block techniques,
recently the combined lumbar plexus and sciatic
nerve block (CLSB) technique is recommended
especially for high-risk patients.
Ho AM, Karmakar MK. Combined paravertebral lumbar plexus and parasacral sciatic nerve block for
reduction of hip fracture in a patient with severe aortic stenosis. Can J Anaesth. 2002;49(9):946-50
.
Introduction
Potential outcome-influencing factors are
: mortality
: deep vein thrombosis (DVT)
: pulmonary embolism
: postoperative confusion
Shih YJ, Hsieh CH, Kang TW, Peng SY, Fan KT, Wang LM. General Versus Spinal Anesthesia:
Which is a Risk Factor for Octogenarian Hip Fracture Repair Patients? Int J Gerontol.
2010;4(1):37-42.
 Rodger et al. reviewed of 141 RCT (9559 pts) showed
a relative risk reduction in several complications
within 30 days of surgery compared to GA.
(for repair of hip fractures.)
 Complication
Risk reduction
Mortality
30%
Blood loss
Respiratory depression
Pneumonia
DVT
Pulmonary embolus
MI
55%
59%
39%
44%
55%
33%
Introduction
Total mortality following traumatic fractures
in geriatric patients can be as high as 20% with
a peak between day 6 and 16 (evidence level).*
Congestive heart failure, myocardial infarction,
pneumonia and pulmonary embolism are the
most common causes of death.
*Shih YJ, Hsieh CH, Kang TW, Peng SY, Fan KT, Wang LM. General Versus Spinal Anesthesia: Which is a
Risk Factor for Octogenarian Hip Fracture Repair Patients? Int J Gerontol. 2010;4(1):37-42.
Introduction
Michel et al. reported that in 114 pts treated for
hip fracture, high ASA (III or IV) conferred a
nine times increased risk for mortality at 1 yr.*
Neuraxial anaesthesia is associated with a
significantly reduced early mortality, fewer
incidences of DVT, acute postoperative
confusion and fatal pulmonary embolism. **
* Michel JP, Klopfenstein C, Hoffmeyer P, Stern R, Grab B. Hip fracture surgery: is the pre-operative American Society of
Anesthesiologists (ASA) score a predictor of functional outcome? Aging Clin Exp Res. 2002;14(5):389-94.
** Luger TJ, Kammerlander C, Gosch M, Luger MF, Kammerlander-Knauer U, Roth T, et al.
Neuroaxial versus general anaesthesia in geriatric patients for hip fracture surgery: does it
matter? Osteoporos Int. 2010;21(Suppl 4):S555-72.
Introduction
Nevertheless, there are also
disadvantages such as intraoperative
hypotension, which may lead to CVA
or MI, inadequate RA and urinary
retention, as well as the rare
complications such as epidural
hematoma or infection.*

* Singelyn FJ, Ferrant T, Malisse MF, Joris D (2005) Effects of intravenous patient-controlled analgesia with
morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after
unilateral total hip arthroplasty. RegAnesth Pain Med 30:;452-457.
Introduction
Major orthopedic surgery induces a
hypercoagulable state and the incidence
of intraoperative thrombosis formation is
improved with the use of RA.
Perioperative pharmacologic
anticoagulation therapy might be a
contraindication for neuraxial anaesthesia.
Introduction
The safety of neuraxial anaesthesia in
high risk, elderly patients undergoing
hip surgery regarding to intraoperative
hypotension and anticoagulation therapy
should be emphasized.
 In 1993, with the introduction of
low molecular weight heparin
(LMWH) in the USA, there was
a significant increase in the
incidence of spinal hematomas
after neuraxial anesthesia.
Rowilingson JC, Hanson PB. Neuraxial anesthesia and LMWH prophylaxis in major
orthopedic surgery in the wake of latest American Soceity of Regional Anesthesia
guidelines. Anesth Analg 2005;100:1482-8
Spinal Hematoma
Spinal hematomas are rare but potentially
devastating complication of neuraxial
anesthesia, to cause spinal cord
compression, resulting in paraplegia.
Spinal Hematoma
 The chance of neurological recovery from
paraplegia was reported only in those patients
in whom decompression laminectomy took
place within 8 hours of the onset of symptoms.
 The report by Vandermeulen et al. also
showed that at least 50% of all patients will
have a poor prognosis, with 26% mortality rate
from this complication.
Vandermeulen EP et al. Anticoagulants and spinal –epidural anesthesia. Anesth Analg 1994;79:1165-1177
American Society of Regional Anesthesia
 The devastating nature of spinal hematomas
prompted the American Society of Regional
Anesthesia and Pain Medicine (ASRA) to
convene a Consensus Conference on
Neuraxial Anesthesia and Anticoagulation in
1998 for the purpose of establishing practice
guidelines.
American Society of Regional Anesthesia
 Armed with this information, clinicians
who desired their anticoagulated patients to
receive the benefits of neuraxial anesthesia
could proceed with confidence, knowing
that the risk of bleeding complications had
been minimized.
ASRA Conference Practice Guidelines
1. As thromboprophylaxis with warfarin is initiated,
neuraxial block can be done when the INR is<1.4.
2. Unfractionated heparin administration should be
delayed for 1 h after needle placement and
indwelling neuraxial catheters should be removed
2-4 h after the last heparin dose.
ASRA Conference Practice Guidelines
3. Preoperative LMWH, the needle placement should
occur at least 10-12h after the prophylaxis dose
and at least 24h after the treatment dose.
4. The suggested time interval between
discontinuation of thienopyridine therapy and
neuraxial blockade is 14 days for ticlopidine
and 7 days for clopidogrel.
93 years old, female, FC II-III
DM, HT, DVD (recent CHF-1 wk)
Chronic renal failure, hypoalbuminemia
Aspirin and Plavix
Dx: Fractured neck of femur, Rt
Op: Bipolar hemiarthroplasty
Fractured hip in CAD patient taking Plavix
Two questions to ask
1. Delay operation for 7 d after stopping plavix?
2. Is it safe to perform neuraxial anesthesia in an
extreme aged, CAD patient with plavix?
Delaying Surgery, does this affect mortality?
 Mortality associated with delay in operation
after hip fracture.
BMJ 2006;332:947-950 ((Dr Foster)
-130,000 cases, 18,500 deaths in hospital (14.3%)
(April 2001 to March 2004)
 Delay in operation associated with
increased risk of death in hospital.
Are we blamed for the delay?
Is it safe to perform neuraxial anesthesia?
 The consensus statements are designed
to encourage safe and quality patient
care, but cannot guarantee a specific
outcome.
 Regrettably, minimization does not
equate to elimination of risk.
Is it safe to perform neuraxial anesthesia?
 Sympathetic blockade with spinal or
epidural anesthesia may be poorly
tolerated especially in
- extreme aged patient
- the presence of hypovolemia
- heart diseases
Is it safe to perform neuraxial anesthesia?

The only method available to eradicate
bleeding complication risk associated with
neuraxial anesthesia, regardless of the
patient’s anticoagulated state, would be to
avoid the neuraxial technique and go for
PNB alternatively.
Anesthesia is crucial to the management
of these patients
This situation has refocused
our interests in
regional
anesthesia and
analgesia with
continuous
peripheral nerve
blocks (CPNB).
 In the study of Chelly and colleagues described their
experience in 670 patients receiving lumbar plexus
CPNB for total hip surgery along with warfarin
thromboembolic prophylaxis.
 One-third of the patients in the Chelly and colleagues
study had an international normalized ratio (INR) >1.4
which is the highest Conference recommended limit
for the removal of neuraxial catheters. There were no
catheter-related bleeding complications.
Chelly JE et al. International normalized ratio and prothromin time values before the removal of a lumbar plexus
catheter in patients receiving warfarin after total hip replacement. Br J Anaesth 2008; 101:250-4.
Evidence-based medicine
A prospective survey of 103,730 patients
reported a significantly lower incidence of
serious complications, such as cardiac arrest
and neurologic injury, in patients with PNBs
compared with patients with neuraxial block.*
* Indelli PF, Grant SA, Nielsen K, Vail TP. Regional anesthesia in hip surgery.
ClinOrthopRelat Res. 2005;441:250-5.
Advantages of PNB over Neuraxial Block
1. Avoid spinal hematoma (paraplegia)
2. Avoid PDPH and backache
3. Avoid hypotension or IV fluid load: elderly,
CAD, LV outflow tract obstruction (AS)
4. Avoid narcotic-related side effects: PONV,
dizziness and urinary retention
5. Provide site specific anesthesia and analgesia
(one-leg anesthesia).
Advantages of PNB over Neuraxial Block
6. Can be used in patients who have contraindication
for neuraxial anesthesia
- post spinal surgery or back pain
- increased ICP
- bleeding dyscrasia: hemophilia (with US)
7. Improved physical therapy, mobility, functional
recovery and facilitating early hospital discharge
8. Increase patient satisfaction
PNB guideline?

The ASRA conference left the issue
suggesting that neuraxial guidelines could
be applied to PNB patients as a
conservative approach while admitting this
“may be more restrictive than necessary”.
May be more restrictive than necessary
 PNB as sole anaesthetic
technique for hip surgery
Sole anaesthetic technique
As sole anaesthetic technique for hip surgery,
the LPB (lumbar plexus block) is likely to be
insufficient.
De Visme et al. described a substantial need for
supplement opioids and sedatives for 27% of the
patients undergoing hip fracture repair under LPB
with additional sacral plexus block.*
*
de Visme V, Picart F, Le Jouan R, Legrand A, Savry C, Morin V. Combined lumbar and
sacral plexus block compared with plain bupivacaine spinal anesthesia for hipfractures in the
elderly. RegAnesth Pain Med. 2000;25(2):158-62.
Sole anaesthetic technique
A meta-analysis by Touray et al.
concluded that there was insufficient
evidence for the use of CLSB (combined
lumbar-sacral plexus block) and sedation as
an alternative to a GA or spinal
anaesthetic for hip surgery.*
* Birnbaum K, Prescher A, Hessler S, Heller KD. The sensory innervation of the hip joint--
Sole anaesthetic technique
Buckenmaier III et al. concluded that a LPB with
perineural catheter and sciatic nerve block with
perioperative sedation is effective alternative to
GA for total hip arthroplasty.
However, the dose of propofol (50-200
mcg/kg/min) and fentanyl (327±102 mcg) used
by the authors resemble GA instead of sedation.
 Buckenmaier CC 3rd, Xenos JS, Nilsen SM. Lumbar plexus block with perineural
catheter and sciatic nerve block for total hip arthroplasty. J Arthroplasty.
2000;17(2):158-62.
Anatomy
To provide anaesthesia & analgesia to the entire
leg, a combination of a LPB; posterior approach
and a high sciatic nerve block is necessary.*
The addition of this sciatic block to a LPB should
also be valuable for hip surgery, because the
posteromedial section of the hip joint capsule is
partially innervated by branches of the sciatic n.**
*Chayen D, Nathan H, Chayen M. The psoas compartment block. Anesthesiology. 1976;45(1):95-9.
**Birnbaum K, Prescher A, Hessler S, Heller KD. The sensory innervation of the hip joint--an anatomical study. SurgRadiol
Anat. 1997;19(6):371-5.
Clinical study at Ramathibodi Hospital
We retrospectively reported
70 traumatic hip fracture
High risk, elderly patients, ASA PS III-IV
To determine
: the efficiency of CLSB as sole anaesthetic
: the safety and the complication related to CLSB
: the patient outcomes.
Comorbidity
:
Currently taking anticoagulants
: Heart diseases
: Hypertension
: Vascular diseases
: Chronic kidney diseases
: Acute renal failure
: Respiratory diseases
: Old CVA
: Endocrine disorders
48
33
40
4
14
3
8
12
13
CLSB Technique
 LPB
: the technique described by Capdevila
:18-G insulated Tuohy needle or 21-G needle for
single shot technique (in anti-coagulated patients)
: was inserted & advanced perpendicular to the
skin in all planes to contact the L4 T-processs.
: the needle is “walked off” either superiorly or
inferiorly approximately 1-2 cm. deeper.
CLSB Technique
: Using nerve stimulation, quadriceps contraction
is obtained with a stimulating current of 0.4 mA
: Using in combination with US guided for anticoagulated patients.
: A mixture of 0.5% levobupivacaine and 2%
lidocaine with epinephrine 1:200,000 (1:1) 20 ml
was injected slowly in aliquots after aspiration.
CLSB Technique
 Sciatic nerve block
: using the transgluteal or parasacral approach.
: A 100-mm, 21 gauge insulated needle was
inserted, foot plantar flexion or dorsiflexion was
elicited with a stimulating current 0.4 mA.
: The same LA mixture 20 ml was injected
Result
We reported the successful used of CLSB as
sole anaesthetic.
The need for GA was not encountered in all pts.
There was one patient developed mild hypotension
and was treated with only ephedrine 5 mg IV.
Result
Intraoperatively, they needed only small
doses of : midazolam (1-3mg)
: fentanyl (25-50 mcg)
and/or propofol (15-30 mcg/kg/min)
without any additional airway maneuver or
instrumentation.
Result
The operation time lasted for 1-5.5 hr
(mean 3.16±SD1.02 hr).
 Right after operation, all patients were awake
with hemodynamically stable and stayed at
PACU 30-60 min before transfer to ICU or
ward.
Result
 The rescue drugs required for pain: the first 24 hr
: morphine (mean 4.11±SD1.98 mg) in 34 pts
tramadol (mean 73±SD17.00 mg) in 16 pts
fentanyl (mean 31.25±SD12.5 mcg) in 4 pts
paracetamol (500 mg) orally only in 16 pts.
 There were 36 patients admitted in ICU due to
medical conditions and majority of the patients
stayed only one nightlong.
Result
There was one patient with septic prosthetic hip,
ASA IV, dead 2 months after surgery due to sepsis
with pneumonia and uncontrolled atrial fibrillation.
All patients with pre-existing cognitive dysfunction
were stable as their base line except one patient who
had psychological disorder progress worse and
required psychologist attention.
Result
Patient satisfaction with the anaesthetic technique
was measured in all patients, except 11 patients
who had pre-existing cognitive dysfunction, at
Day1 postoperative period using a verbal rating
scale (VRS 0-10). All patients rated as VRS≥ 8.
The median length of hospital stay was 5 days
(max 60, min 3)
Result
We have not found any incidences of
: nerve injury
: epidural spread
: local anesthetic toxicity
: bleeding complication related to needle
insertion ex: retroperitoneal haematoma
Discussion
CLSB should not be used routinely and
considered only when RA is strongly
preferred but central neuraxial blocks are
contraindicated.
It is important to consider risk-benefit on a
patient-by-patient basis.
As with all anaesthetic procedures,
complications rates reflect in part the skills
and judgments of the operator.
Discussion
Until now, there is no published data
describing optimal dosing for LPB or sciatic
block when using as the combined block
technique.
Furthermore, one must exercise caution when
considering a LPB in anti-coagulated patients,
we used ultrasound guidance in combination
with nerve stimulation for the blocks.
Discussion
The widespread use of
anticoagulation in patients
undergoing hip surgery mandates
further research to make CLSB
technique more optimal and more
safety for hip anaesthesia.
Conclusion
The magnitude of the benefits of the
CLSB is clinically important as sole
anaesthetic for hip fracture surgery even
in patients who have contraindication
for neuraxial anesthesia or patients with
poor general health status.
Conclusion
The advantages of CLSB are
encouraging technique to operate
high risk, hip fracture patients.
We found a very good clinical
efficiency of CLSB in hip surgery
without any serious complications.
THANK YOU FOR YOUR ATTENTION