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

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’ Bureau - Halyard Health

My Perspective Large academic hospital Freestanding Orthopaedic ASC NAPA Private practice hospital Mid-Atlantic 14 Hospitals 6 ASCs >350 MDs, CRNAs

HIP ARTHROSCOPY

HIP ARTHROSCOPY Lumbar Plexus Block • Genitofemoral • Lateral femoral cutaneous • Femoral • Obturator

Cross-sectional view • Genitofemoral • Lateral femoral cutaneous • Femoral • Obturator c/o Dr. Michael Ashmore

Lumbar Plexus Block • Sensory - Anterolateral, medial thigh - Knee - Medial shin • Motor - Quadriceps - Adductors

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

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.

Why My Surgeons Like Lumbar Plexus Blocks... • Dense block • Better than a spinal... - Hemodynamic stability - Less urinary retention - Preserves function in the nonoperative limb • Excellent pain control BUSY - Minimize opioids, less PONV • Faster PACU discharge

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

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

Fascia Iliaca Block ERAS for... • Hip arthroscopy • Hip fracture • Hip arthroscopy • THR • Hip fracture • THR Mayo Foundation for Medical Education.

Fascia Iliaca Block • Lateral femoral cutaneous • Femoral • Obturator • “Anterior approach lumbar plexus” • Less dense versus lumbar plexus

Fascia Iliaca Block • Compartment block = High volume Fujihara. FICB. J Orthop Sci. 2013. • 50 - 60 cc local anesthetic

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

Bow-Tie SUPERIOR INFERIOR • Compartment block = High volume Sartorius • 50 - 60 cc local anesthetic Internal Oblique Fascia Iliaca Iliacus 50 cc Compartment Block 20 cc 0.2% Ropivacaine 30 cc 0.5% Ropivacaine

HIP FRACTURE Placebo FIB Incidence of Delirium 23.8% 10.78% Mean Duration of Delirium 10.97 days 5.22 days

Fascia Iliaca Block No Block FIB cath POD 0 Pain 4.1 1.7 POD 1 Pain 2.9 1.4 Ave LOS 5.9 days 4.8 days

TOTAL HIP ARTHROPLASTY Neuraxial Anesthesia • >380,000 THR, TKR Lower 30-day mortality • 400 hospitals Decreased length of stay • GA vs Neuraxial Decreased cost Lower in-hospital complications Memtsoudis, S., et al, Anesthesiology 2013 May; 118(5): 1046 - 1058.

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? Auyong, DB, et al, Reduced Length of Hospitalization in Primary Total Knee Arthroplasty Patients. J Arthroplasty 2015. Zayas, VM. Dose response relationships for isobaric spinal mepivacaine. Anesth Analg 1999 Nov; 89(5): 1167 -71.

Neuraxial anesthesia versus General Anesthesia • 13 studies Neuraxial Anesthesia • n = 362,029 Decreased incidence of SSI • GA vs Neuraxial Zorrilla - Vaca, A. et al., Regional Anesthesia and Pain Medicine. 2016; 41: 555-563.

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