TOPICAL ISSUES OF ANESTHESIA SUPPORT FOR PATIENTS WITH PROXIMAL FEMUR FRACTURES Akhtyamov I.F., Safin R.R., Khan Kh.Ch.
Kazan State Medical University,
Tatarstan Republic Clinical Hospital, Kazan, Russia
Hip fracture, and pertrochanteric and subtrochanteric fractures of the hip [1] were and are still the epidemiological problem. In USA, their rate is 0.79 % in women older than 65 and 0.37 % in other population. The rate of 30-day mortality is 11.9 % in women and 21.8 % in men [3, 4]. Such specific injury is based on osteoporosis, which is the direct result of the ageing of the population. Wide use of bisphosphonates as a preventive measure did not improve the statistics significantly; moreover, persons older 80 did not show any results of sufficient clinical efficiency in treatment of osteoporosis [2]. As addition to osteoporosis, the other causes of frequent injuries are limited mobility of the joints, coordination disorders and worsening vision in older people.
There is not any alternative for surgical treatment of proximal hip fractures at the present time. Osteosynthesis and joint replacement are the part of practice in the specialized facilities. Although the risk of unfavorable outcome exists, it is lower as compared to the case of refusal from it. What is success of the surgical treatment? First of all, it depends on choice of a treatment technique and appropriate anesthesia.
The present practice of choice of anesthesia technique
As for practical solution of the issues of anesthetic management in surgical management of proximal fractures of the hip, one should note the sufficient amount of the complex clinical recommendations, such as Australian and New Zealand Guideline for Hip Fracture Care – Improving Outcomes in Hip Fracture Management of Adults (2014) [5], Management of hip fractures in the elderly evidence-based clinical practice guideline (2014) [6], Hip fracture: management NICE guidelines (2015) [7], and Clinical recommendations for anesthetic management of proximal hip fractures in older patients. However they do not allow clear selection of a method for anesthetic management. The basis of the clinical recommendations is usually the integral estimation of results of large-scale multi-center studies.
In most cases, the choice is made on the basis of the available clinical experience in general or local anesthesia in surgery for the hip joint in arthrosis deformans, with further transition of this experience to the practice of surgical management of acute injury [9, 10].
An American study (2010-2012) included 20,936 medical records of the patients who had received the planned or primary joint replacement surgery. It showed some advantages of regionary anesthesia as compared to general analgesia. Lower amount of time for surgical intervention showed the fact of presence of more comfortable conditions for work of the surgical team. At the same time, general anesthesia resulted in increasing time of stay in the postsurgical follow-up room, caused the necessity for prolonged lung ventilation and increased the time intervals from recurrent intubations. General anesthesia was associated with 5-fold increase in the rate of cardiac arrest as compared to regionary analgesia. The blood loss was higher in general anesthesia and required for transfusion of blood components. After such anesthesia, the surgical patients resumed independent moving significantly later [11]. Another study analyzed the data of 10,868 patients and showed the decreasing mortality (0.19 % vs. 0.8 %) and the decrease in hospital stay (5.7 days vs. 6.6 days) in spinal anesthesia for planned implantations of hip and knee joints [12].
However direct extrapolation of such experience is not optimal for acute injury in fractures of the proximal segment of the hip. After surgical treatment, the long term and short term posttraumatic mortality demonstrates the higher dependence on the factors, which are not directly associated with one other technique of intrasurgical analgesia [13].
The features of presurgical period
The issue of timeliness of surgery for older patients has a strategic importance as compared to the tactical issues of choice of analgesia. Currently, it is considered that a patient is to be operated within 48 hours after hospital admission. Surgery can be performed later only in exception cases with serious life-threatening complications. Such complications include myocardial infarction, cerebral stroke, pulmonary embolism, diabetic coma etc.
It is recommended to perform the surgery at day time, but not during night duty. The urgency of the situation requires for rapid and appropriate preparation to the surgery with participation of the anesthesiologist-intensivist for normalizing the circulating blood volume, correction of water-electrolyte balance disorders, hypoxia, anemia, and prevention of infectious and thromboembolic complications [14].
The risks appearing in surgical treatment of the proximal hip fractures are quite high, primarily, due to concurrent chronic diseases in older patients. If the fact of constant uptake of hormones, cytostatic agents, beta-blockers or agents for lipid metabolism normalization with necessity for correction of chronic diseases is identified, then presurgical cancellation of these drugs is undesirable since it results in increasing anesthesiology risk.
The posttraumatic pain syndrome at the background of psychoemotional stress creates some serious obstacles to provision of care and hygienic procedures, including the measures for preparing the patient to a surgical intervention. The pain significantly limits the patient’s activity, promotes the exacerbation of cardiovascular diseases, formation of congestion pneumonia and thrombosis in superficial and deep veins. The altered life style and physical helplessness can lead the older patient to reactive psychosis in view of delirium. The presurgical limitation of water and food, frequent presurgical use of narcotic or sedative agents, older age, disordered vison and hearing, polypragmasy, urinary bladder catheterization, and fixation of the patient promote the development of delirium. Therefore, adequate presurgical treatment of pain syndrome improves the psychoemotional condition and significantly decreases the risk of the above-mentioned complications [15]. Moreover, it is important to help the patient to orientate in the altered system of time and space. It is necessary to offer the daily use things: glasses, the hearing device and dental prosthesis. The presence of close relatives may promote the feeling of safety and adequate orientation in the new situation [16].
The example of the modern approach to treatment of pain syndrome in proximal hip fractures is the work of the trauma clinics of the United Kingdom. The greatest proportion of the British clinics (about 62 %) uses the simultaneous regionary anesthesia with ascending ileofascial block with the single shot. In other clinics, pain syndrome after hip fractures is treated with common analgetics due to absence of the qualified personnel, navigation equipment and other various and acceptable reasons. However a clear trend to the increasing use of regionary blocks in presurgical treatment of pain syndrome is used [17]. Helplessness, changes in life style and environment at the background of pain syndrome causes severe stress. Therefore, stress ulcers have to be prevented with proton pump inhibitors, H2-receptor blockers and sucralfate. The preventive use of agents should last at least 7 days. One should remember about the increasing risk of congestive pneumonia after prescription of ion pump inhibitors and H2-receptors [18, 19].
Prevention of possible complications
The non-ambulatory older patients with limited mobility have the high risk of bed sores. The prevention of bed sores is initiated from the moment of hospital admission. The best measure is use of special pneumatic mattress, which provides the continuous intermittent low pressure under the patient’s body and extremities [20].
Mechanic compression of the lower extremities, which is initiated before surgery, decreases the rate of venous thrombosis in the postsurgical period more than two times [21]. It should be initiated immediately after hospital admission [22]. Protty MB et al. recommend to anaesthetize the injured extremity before use of compression stockings [23].
If surgery is performed within the time interval less than 12 hours after admission, it is necessary to prescribe the anticoagulants after surgery. However in absence of a possibility for operation within 12 hours after admission, the preventive dosage of low molecular weight heparin (LMWH) is used before surgery. If oral anticoagulants are used, the time of preparation for surgery is limited to 48 hours [24]. If rivaroxaban is used, it is cancelled, and therapeutic dosages of LMWH is used under control of INR (international normalized ratio). The surgical intervention is indicated in INR < 1.5. If warfarin is used, INR > 1.5 can be corrected within 24 hours by means of administration of 20 mg of vitamin K. During the postsurgical period, the use of preventive measures of LMWH can be prolonged to 35 days after surgery [25].
The single presurgical use of the antibiotic significantly decreases the rate of infectious complications in the region of the postsurgical wound and prevents the development of urinary and respiratory tract infections. The economic and clinical efficiency is comparable to long term antibiotic prevention [26]. Intravenous administration of cephalosporins (the use of the first and second generation is optimal) is recommended one hour before a skin incision, fluoroquinolones – two hours before surgery. If additional risk factors of infection present (long term operation, massive blood loss and others), the recurrent use of the antibiotic is necessary [27].
Intrasurgical analgesia
The real intrasurgical anesthesia protocol is virtually the landmark of one or another medical institution. Moreover, the existing traditions, which determine the choice between general or regionary anesthesia, sometimes make the impassable barrier on the way of implementation of new techniques in work of specialists. However unbiased third-party assessment of results of activity of a clinical facility challenges the conventional stereotypes. It has been shown (the level A evidence) that the results of surgical management in various types of proximal femur fractures do not show any statistical difference in 30-day mortality in patients who were operated under general anesthesia as compared to regional one [28], despite the fact that Van Waesberghe J. showed that the hospital mortality and hospital stay were higher in patients under general anesthesia as compared to regionary one [29].
From pathophysiological perspective, it is quite possible that regionary anesthesia techniques create more favorable conditions for union of bone fragments since an experimental study of femur bone fractures in rats showed the positive influence of femoral nerve blockade on increasing expression of immunohistochemical markers of recovery [30]. However use of ascending ileofascial block in femoral bone fractures in the human has some differences from experimental animals.
The Cochrane database does not include any evidence of a relationship between an anesthesia method and decreasing mortality rate after surgical treatment of hip fracture [31]. At the same time, the appropriateness of use of the peripheral neural block for decreasing pain syndrome, reducing time of patient’s mobilization and prevention of congestion pneumonia has the high level of the evidences [32].
Presurgical anesthesia with regionary blockades significantly improves the condition and the postsurgical course in patients. Also it includes the cases when general anesthesia is the main technique of surgical analgesia, but upon condition that postsurgical treatment of pain syndrome is performed with some regionary blockades [33].
Conduction of spinal anesthesia as the most common technique of regionary analgesia is hindered by the fact that lateral or sitting position is associated with strong pain in the fracture region. In this case, pain syndrome can be efficiently corrected with only accurate introduction of opioid analgetics. After their introduction lateral positioning is performed simpler, but depressive influence on the central nervous system causes the significant difficulties with independent sitting position.
The alternative for intravenous introduction of narcotic analgetics is ascending ileofascial blockade with injection of a local anesthetic agent in the place of the output of the femoral nerve out of the fallopian ligament. Ultrasound navigation gives the maximal efficiency of technical realization of this type of nervous blockade, but not as the independent technique of analgesia in a surgical intervention [34, 35]. One should pay attention to the fact that postsurgical analgesia with ascending ileofascial block is not so efficient as before beginning of surgery. The reason is the circumstance that tissues go out of the field of innervation of lumbar plexus due to additional surgical aggression [36].
Possible risks of anesthesia in patients with fractures of proximal femoral bone
Without considering all pros and cons, one should never select spinal, epidural or general anesthesia. Each anesthesia method has both advantages and disadvantages. The positive moments of modern general anesthesia in high tech format is availability of monitoring of CO2 expiratory level (decreasing PetCO2) and in the arterial blood (increasing PaCO2) that identify the early development of pulmonary embolism. It gives a possibility for timely prescription of anticoagulants and placement of the cava filter [37]. The multi-center analysis of the results of 2,162 operations of total hip and knee replacement showed that single-stage spinal anesthesia had the highest risk of thromboembolic complications because of their later identification [38].
Moreover, when selecting analgesia technique one should always remember about some specific complications of the central neuroaxial anesthesia, which can predictably or unpredictably appear in necessary systematic administration of anticoagulants or presence of occult neurological disease [39]. Before epidural catheterization one should always remember about such complication as epidural hematoma. Early clinical signs of this complication can be considered as the extremely strong epidural block and, therefore, ignored. According to the literature data, the rate of this complication is 1:20,000, but the risk significantly increases in administration of anticoagulants [40, 41]. Some episodic cases of epidural hemangioma with possible risk of severe consequences have been described [42]. However the literature findings show some spontaneous cases of epidural hematoma of the spinal cord, which are not associated with epidural catheterization [43].
Summing up the results of the review of surgical analgesia and treatment of pain syndrome in patients with proximal femoral bone fractures, it is necessary to note the absence of the ideal method without disadvantages. The use of opioid analgetics is limited by side effects with breathing suppression, nausea, vomiting and itching. Non-narcotic analgetics do not have sufficient pharmacological power for correction of pain syndrome. At the same time, the peripheral nervous block (and epidural) can be associated with toxic-resorptive complications, which may require for lipid reanimation.
Postsurgical anesthesia
Now it is considered that the standard prolonged epidural block prevents the process of postsurgical rehabilitation despite the fact of effective analgesia. Therefore, the time of its use is better to be limited by one day after the intervention. After surgery, the optimal variant is multimodal anesthesia with regular estimation of pain syndrome intensity. If any contraindications are absent, it is recommended to prescribe acetaminophen (paracetamol) each six hours. If the effect is insufficient, tramadol or selective non-steroidal anti-inflammatory drugs are prescribed.
The loss of sensitivity in a healthy lower extremity in epidural blockade can cause the compartment syndrome. This complication develops at the background of hypotonia, which accompanies spinal or epidural blockade and is traditionally considered as their positive feature. However in combination with bandaging the non-operated lower extremity at the background of spinal or epidural block, muscular subfascial ischemia can develop as result of edema or compression that may require for urgent fasciotomy [44].
We consider that the maximally efficient and safe analgesia for femoral bone fractures can be performed exclusively with the balanced multimodal approach, which combines the various techniques for pain management and significantly decreases the possibility of side-effects of monotherapy of pain syndrome [45, 46].
CONCLUSION
The study of the available information sources reviewing the issues of anesthesia has showed that selection of analgesia for proximal femoral bone fractures can significantly differ from analgesia in planned surgery even in identical patterns of an intervention. It is certain that regionary analgesia techniques for admission and treatment of planned patients have some advantages over general analgesia such as lower blood loss, decreasing mortality, number of bed days and earlier activation. However the situation changes in acute trauma. The modern clinical recommendations do not give the uniform answer about correct selection of anesthesia for proximal femur fractures. Mostly, anesthesia techniques are selected according to technical sources of a clinic and costs of materials. Considering almost equal mortality rate from one side, and high amount of patients and lower costs of materials from other side, the selection is made in favor of spinal anesthesia. The task of the anesthesiologist is not limited only by analgesia during surgery. His or her tasks also include the maximally fast preparation to surgery after admission, and provision of continuation of anesthesia at the stage of surgical management, and appropriate management of the patient in the early postsurgical period. The basis of the modern clinical recommendations for treatment of proximal femoral bone fractures is the complex approach determining the uniform concept of participation of anesthesiologist-intensivist and high level of work beginning from time of mobilization and activation of the patient in the postsurgical period.