Cutting Edge Techniques in Hip Anesthesia: Blocks and Beyond! - - PowerPoint PPT Presentation

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Cutting Edge Techniques in Hip Anesthesia: Blocks and Beyond! - - PowerPoint PPT Presentation

Jan 10, 2024 277 likes •523 views

Cutting Edge Techniques in Hip Anesthesia: Blocks and Beyond! Sonia Szlyk, MD Director of Regional Anesthesia North American Partners in Anesthesia, Mid-Atlantic Division INOVA Fair Oaks Hospital, VA Disclosure National Speakers

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SLIDE 1

Cutting Edge Techniques in Hip Anesthesia: Blocks and Beyond!

Sonia Szlyk, MD

Director of Regional Anesthesia North American Partners in Anesthesia, Mid-Atlantic Division

INOVA Fair Oaks Hospital, VA

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SLIDE 2

Disclosure

  • National Speakers’ Bureau
  • Halyard Health
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SLIDE 3

Large academic hospital Private practice hospital Freestanding Orthopaedic ASC NAPA Mid-Atlantic

14 Hospitals 6 ASCs >350 MDs, CRNAs

My Perspective

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SLIDE 4

HIP ARTHROSCOPY

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SLIDE 5

HIP ARTHROSCOPY

Lumbar Plexus Block

  • Genitofemoral
  • Lateral femoral

cutaneous

  • Femoral
  • Obturator
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SLIDE 6

Cross-sectional view

  • Genitofemoral
  • Lateral femoral cutaneous
  • Femoral
  • Obturator

c/o Dr. Michael Ashmore

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SLIDE 7

Lumbar Plexus Block

  • Sensory
  • Anterolateral, medial thigh
  • Knee
  • Medial shin
  • Motor
  • Quadriceps
  • Adductors
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SLIDE 8

Nerve Stimulator Block Placement

  • 4 cm lateral to midline at level of

intercristal line

  • 6 - 8 cm depth
  • Walk of transverse process
  • Twitch of quadriceps muscle
  • 0.5 mA on twitch monitor
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SLIDE 9

US-guided Block Placement

  • Parasagittal approach
  • Low frequency probe
  • Depth > 6 cm at L3/4
  • Identify transverse process
  • 0.5% Ropivacaine 20 - 25 ml
  • 2 - 3 hr surgical anesthesia
  • 12 - 18 hr analgesia

Karmakar M K et al. Br. J. Anaesth. 2008; 100:533-537.

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SLIDE 10
  • Dense block
  • Better than a spinal...
  • Hemodynamic stability
  • Less urinary retention
  • Preserves function in the nonoperative limb
  • Excellent pain control
  • Minimize opioids, less PONV
  • Faster PACU discharge

Why My Surgeons Like Lumbar Plexus Blocks...

BUSY

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SLIDE 11

Lumbar plexus Lower PACU pain scores Lower periop opioid admin Lower PACU antiemetic admin Longer total hospital time NO difference Postop mod. Harris hip score POD 1 pain score

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NOT a Beginner Block

  • Epidural spread
  • Bilateral sympathectomy --> significant hypotension
  • Bilateral motor block
  • Total spinal
  • Vascular puncture, noncompressible hematoma
  • Nerve injury
  • Local anesthetic toxicity
  • Highly vascular psoas compartment
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SLIDE 13

Fascia Iliaca Block

  • Hip arthroscopy
  • Hip fracture
  • THR

ERAS for...

Mayo Foundation for Medical Education.

  • Hip arthroscopy
  • Hip fracture
  • THR
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SLIDE 14

Fascia Iliaca Block

  • Lateral femoral cutaneous
  • Femoral
  • Obturator
  • “Anterior approach lumbar plexus”
  • Less dense versus lumbar plexus
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SLIDE 15

Fascia Iliaca Block

  • Compartment block = High volume
  • 50 - 60 cc local anesthetic
  • Fujihara. FICB. J Orthop Sci. 2013.
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SLIDE 16

Fascia Iliaca Block

Edge of probe at ASIS Insert needle in-plane from distal edge of probe

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SLIDE 17

Bow-Tie

  • Compartment block = High volume
  • 50 - 60 cc local anesthetic

Sartorius Internal Oblique Iliacus

SUPERIOR INFERIOR Fascia Iliaca

50 cc Compartment Block 20 cc 0.2% Ropivacaine 30 cc 0.5% Ropivacaine

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SLIDE 18

Incidence of Delirium

10.78% 23.8%

Mean Duration of Delirium

5.22 days

FIB Placebo

10.97 days

HIP FRACTURE

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SLIDE 19

Fascia Iliaca Block

No Block FIB cath

POD 0 Pain POD 1 Pain Ave LOS

4.1 1.7 2.9 5.9 days 1.4 4.8 days

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SLIDE 20

Neuraxial Anesthesia

Lower 30-day mortality Decreased length of stay Decreased cost Lower in-hospital complications

Memtsoudis, S., et al, Anesthesiology 2013 May; 118(5): 1046 - 1058.

TOTAL HIP ARTHROPLASTY

  • >380,000 THR, TKR
  • 400 hospitals
  • GA vs Neuraxial
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SLIDE 21

Mepivacaine Spinal

  • “Short-acting spinal”
  • 3 cc Mepivacaine 1.5%
  • Alternative to bupivacaine spinal
  • ~ 2.5 hr motor, ~ 3 hr sensory blockade
  • Less postoperative urinary retention?

Zayas,

  • VM. Dose response relationships for isobaric spinal mepivacaine. Anesth Analg 1999 Nov; 89(5): 1167 -71.

Auyong, DB, et al, Reduced Length of Hospitalization in Primary Total Knee Arthroplasty Patients. J Arthroplasty 2015.

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SLIDE 22

Neuraxial Anesthesia

Decreased incidence of SSI

Zorrilla - Vaca, A. et al., Regional Anesthesia and Pain Medicine. 2016; 41: 555-563.

  • 13 studies
  • n = 362,029
  • GA vs Neuraxial

Neuraxial anesthesia versus General Anesthesia

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SLIDE 23

Stack the Deck…

  • Experienced anesthesiologist
  • Routinely performs neuraxial and peripheral blocks
  • Multimodal analgesia
  • Enhanced-Recovery protocols
  • Stay tuned for updates on role of anesthesia in

perioperative outcomes