Background & Aims

The elderly patients with hip fracture remain a medical challenge for the anesthesiologist, mainly because of the significant comorbidities, placing them at high risk for GA. Often neuro-axial anesthesia is contraindicated due to the prevalent use of anticoagulant medications. Current guidelines emphasize surgery within 48 hours of admission to avoid poorer outcomes associated with delayed procedures. Fascia Iliaca Block (FIB) has emerged as an opioid-sparing technique for these patients reducing perioperative morbidity, pain scores, and length of stay. The lumbar plexus (LP) innervates the hip mainly through the femoral nerve, obturator nerve, and lateral femoral cutaneous nerve. Ultrasound-guided supra-inguinal FIB facilitates a more cephalad spread of local anesthetics compared to the infra-inguinal method targeting those branches proximally in the LP. In this case report, we describe the use of supera inguinal FIB with sedation as the primary anesthesia for a frail elderly patient.

Methods

Case presentation:
91 years old male, professor in Mauritius, with history of myasthenia gravis, Atrial fibrillation, aortic insufficiency, lumbar spinal stenosis, and CHF, presented to the Emergency room following a mechanical fall with a right intertrochanteric hip fracture. At baseline- independent of most activities of daily living.

Pre-operative Ultrasound-guided Supra Inguinal FIB:
At the holding area, an Ultrasound-guided supra inguinal FIB with Bup 0.5% 20 ml + Mepivacaine 2% 10 mL was conducted with a 50mm 22g needle. A linear US probe was positioned perpendicular to the inguinal ligament and needle insertion was in an in-place approach with the needle pointing to the cephalic direction to aim for LP spread. Visualization of local anesthetic spread above the ileac muscle as well as around the femoral nerve following the injections was verified.

Results

Intra-operative course: Short gamma nail insertion was completed in 40 minutes without complications. Sedation was facilitated using midazolam 1 mg, propofol infusion 50–100 mcg/kg/min, and ketamine boluses (20 mg at induction and 10 mg during the case). The patient maintained spontaneous ventilation with High-flow nasal cannula and capnography. All vitals were stable throughout the case.

Post-operative course:
In PACU pain was well controlled, no nausea, or delirium. No pain medications were given. Post-operative day 4 patient was assessed by the anesthesia team, he didn’t recall any events during the procedure, had no pain in the first night following surgery, and was very satisfied with anesthesia management. Post-op course was complicated with UTI due to traumatic foley placement and epididymitis which was treated with antibiotics, and rapid atrial fibrillation treated with metoprolol. warfarin therapy was initiated with concurrent enoxaparin until reaching therapeutic INR.

Conclusions

This case report is added to five other cases published of which supra inguinal FIB was used as surgical anesthesia for hip repair. This could be explained by the cephalic distribution of LA along the ileac muscle, towards the LP in a supra-inguinal approach of FIB. Innervation of the hip joint consistently involves articular branches of the femoral nerve and the Obturator nerve, which supply the anterior capsule. The posterior capsule consistently receives innervation from the nerve to the quadratus femoris (derived from anterior divisions of ventral rami of L4- S1). While evidence shows that other nerves including the superior and inferior gluteal nerves, accessory Obturator nerve and sciatic nerve may also contribute, their involvement is less consistent. Supra-inguinal FIB may be an alternative anesthetic management for hip fracture procedures in the frail elderly population when spinal anesthesia is contra-indicated.

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Presenting Author

Tamar Hayuni

Poster Authors

Tamar Hayuni Kosovsky

MD

Soroka Medical Center

Lead Author

Abir Chisti

MD

Beth Israel Deaconess Medical Center

Lead Author

Shiri Savir

MD MPH

Beth Israel Deaconess Medical Center

Lead Author

Topics

  • Pain in Special Populations: Elderly