**3. Hip infringements and associated surgeries**

Hip fracture implies a fracture of the upper quarter of the femoral bone. Fracture line stretches indifferent directions depending on the force that causes it. According to their anatomical location, hip fractures are classified as intracapsular (IF), which involves the femoral head and neck, and extracapsular (EF), which includes intertrochanteric, trochanteric and subtrochanteric fractures.

Blood loss from an IF at the time of injury is minimal because of the poor vascular supply at the fracture site and tamponade affected by the capsule. Occasionally, fractures without displacement may be treated conventionally, but there is a 30–50% risk of subsequent displacement. Current preference is for all intracapsular fractures without displacement to be treated by internal fixation with multiple screws or a sliding hip screw. Untreated disruption to the capsular blood supply of the head of the femur by a displaced intracapsular fracture can lead to avascular necrosis of the bone, resulting in a painful hip of limited function. Therefore, surgical treatment involves cemented hemiarthroplasty. Blood loss from an EF may exceed one litre; the larger the bone fragments, the greater the blood loss.

In addition, greater periosteal disruption causes EFs to be more painful than an IF. EF is fixed surgically using either a sliding hip screw, (intertrochanteric fractures) or less commonly, a proximal femoral intramedullary nail (subtrochanteric fractures).

In the developed countries, the number of hip replacements has rapidly increased throughout the twenty-one century [6]. This trend is mainly due to the population ageing and according to the lengthening of life expectancy [7].

*Regional Anaesthesia for Hip Surgeries DOI: http://dx.doi.org/10.5772/intechopen.104086*

The rational and the main features of Tissue Sparing Surgery (TSS) concept are maximum respect of anatomy, restoration of joint biomechanics, and removal of degenerated tissues, preserving the healthy ones. So, the prosthesis should just 'integrate' the joint instead of substitute it. The purposes of these techniques are to reduce blood loss, post-operative pain and hospital length of stay while improving recovery and ambulation [8, 9].

Hidden blood loss should not be ignored in patients who underwent hip hemiarthroplasty for displaced femoral neck fractures, as it is a significant portion of total blood loss. A better understanding of HBL after hip hemiarthroplasty may help surgeons improve clinical assessment and ensure patient safety [10].

#### **3.1 Timing of surgery**

Recommendations that have been introduced in 1989 by the Royal College of Scientists are that ideally, surgery should be performed within 48 h of hospital admission after hip fracture. In April 2010, new target of 36 h has been accepted in the first place in England and Wales. There are meta-analyses that indicate that delaying surgery beyond 48 h from admission is associated with prolonged in patient stay, increased morbidity (pressure sores, pneumonia, thromboembolic complications) and increased mortality. But, surgery is often delayed because of the need for additional investigation in elderly patients and their preoperative preparation, although there is no evidence to suggest that outcome is improved by delaying surgery to allow preoperative physiological stabilisation. However, the benefits of expedited surgery must be balanced against the risks of certain untreated conditions [11].

### **4. Central neuraxial anaesthesia in hip trauma and surgery**

#### **4.1 Pain in hip trauma and surgery**

Pain sensation varies in this type of fractures and surgical reconstructions depending on intensity, quality and duration of pain stimuli involving nociception, inflammation and nerve cell remodelling [12]. Also, nociceptive information strongly influences brain centres for regulating homeostasis. This includes also psychological conditions, such as fear or anxiety that can significantly influence the experience of pain. So, understanding neuroanatomical organisation of central processing of nociceptive information is of great clinical importance.

Proximal femoral fractures are known for most painful injuries and in the elderly, this pain syndrome can even change the cognitive functions. Femoral fractures are usual emergency and characteristically happen in elderly population, which is most vulnerable to the deleterious effects of poorly managed pain, and adverse effects of both drugs and post-operative pain; thus, achieving effective analgesia is particularly difficult because it is necessary to personalise the treatments and, at the same time, the ineffective analgesia may lead to serious complications such as delirium. Untreated severe pain can increase patient's fear and anxiety, lead to aggressive behaviour and disturbance of cognition, and have an unfavourable effect on physiological parameters [11]. These patients jeopardise of perioperative morbidity and mortality, which can be reduced with prompt surgical treatment and punctual quality rehabilitation.

#### **4.2 Neuroendocrine and immune response**

Patients with proximal femoral fractures show prolonged adrenocortical response to injury. It is known that elevated cortisol concentrations persist in elderly patients 2 to 3 weeks after injury than in young patients with similar injuries or even more severe. Significantly higher cortisol levels can last up to 8 weeks after injury [12]. The stress hormone cortisol affects the cognitive function, memory and learning, reduces immunity and bone density, and increases body weight, arterial pressure, cholesterol blood levels and heart diseases. Alterations of cognitive status after surgery may present in the form of delirium or, more delicately, as post-operative cognitive dysfunction (POCD). Hyperactivity of the hypothalamo-pituitary-adrenal (HPA) axis with higher cortisol levels is involved in the pathophysiology of delirium [6]; similarly, association between higher plasma cortisol levels and POCD in aged patients following hip fracture surgery occurs [7]. Delirium refers to observable changes in consciousness and attention, whereas POCD may refer to a patient exhibiting significant declines from patient's own baseline level of performance in one or more neuropsychologic domains.

Surgery elicits broad alterations in haemodynamic, endocrine-metabolic and immune responses. The inflammatory response is essential for structural and functional repair of injured tissue, as complement, granulocytes, macrophages and many other mediators are required for appropriate wound healing. Injury, caused by trauma or surgery, is connected with the acute disorder of immunological system, which manifests as increased inclination to infections. The inflammatory response is an important determinant of outcome after major surgery. Perioperative excessive stimulation of the inflammatory and haemostatic systems plays a role in the development of post-operative ileus, ischaemia-reperfusion syndromes (e.g. myocardial infarction), hypercoagulation syndromes (e.g. DVT) and pain. Together, these represent a significant fraction of major post-operative disorders. Regional anaesthesiaadministered local anaesthetics prevent or modulate many of these processes.

In the centre of interests, there are the serum-levels of T-helper-1 (Th-1) and T-helper-2 (Th-2) cytokines before and after regional and general anaesthesia and in such a way would like to confirm through the immunological status that the spinal anaesthesia is significantly more favourable for the patient.

Survival depends on the immune system's ability to defend the body against attack from invading pathogens and injury. However, the extent of such a response is of critical importance; deficient responses may result in secondary infections from immunosuppression and excessive responses can be more harmful than the original insult*.*

Cytokine synthesis and release is an essential component of the innate immune system, but inappropriate, excessive production results in a generalised systemic inflammatory response, which damages distant organs.

The consequences of ageing on the immune system are thought to contribute considerably to morbidity and mortality in the elderly. Tumour necrosis factor-α (TNF-α) and intreleukine-6 (IL-6) concentrations are raised in the elderly, and studies have shown that, in response to surgical trauma, the elderly have a magnified and late inflammatory cytokine response [13]*.*

#### **4.3 Neuromodulation in neuraxial anaesthesia**

Regional anaesthesia alone, without surgery, has periodical and minimum effects to immunological system*.* It is established that various anaesthesiological procedures *Regional Anaesthesia for Hip Surgeries DOI: http://dx.doi.org/10.5772/intechopen.104086*

in the same surgery cause various trend of alteration of cytokine level in serum. Spinal anaesthesia results in less immunosuppression, that is maintains the number of Th-1 cells, thus stimulating the cell immunity. Serious disorder of immunological system may cause complications as there are disorders in wound healing, increased number of infections, non-adequate response to the stress, multi-organic suppression and increased incidence of metastases [14, 15].

Surgery is the best analgesic for hip fractures. It can be performed under the general or regional anaesthesia. There are a great number of studies that analysed and compared the effects of both anaesthetic techniques. There are minimal evidencebased analyses for determining the optimal anaesthetic technique for patients undergoing hip fracture surgery.

Consequently, anaesthesiologists tend to use the technique which they are familiar with half, administering neuraxial anaesthesia and the latter general anaesthesia.

Administration of local anaesthetics was designed to provide intraoperative anaesthesia and post-operative analgesia. However, in recent years it has become clear that regional administered local anaesthetics have benefits far beyond anaesthesia and pain relief; indeed, the technique has significant impact on the outcome of major surgical procedures. A recently published meta-analysis suggests that neuraxial anaesthesia using local anaesthetics decreases overall mortality by approximately one-third, and reduces the odds of DVT by 44%, PE 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by 59% [16]. There were also reductions in myocardial infarction and renal failure. In addition, epidural anaesthesia using local anaesthetics has been shown to attenuate the endocrine and metabolic response to upper abdominal surgery, to reduce post-operative ileus and to shorten duration of intubation and intensive care stay in patients undergoing abdominal aortic surgery.

Local anaesthetics modulate the inflammatory response *in vivo.* They prevent or reduce inflammatory disorders, such as reperfusion injury in heart*.* Beneficial effects of local anaesthetic treatment in inflammatory bowel diseases are well documented*.* In contrast to corticosteroids, which depress the inflammatory response and impact negatively on post-operative outcome, local anaesthetics selectively inhibit only overactive responses of the inflammatory and haemostatic systems without affecting normal function*.* Local anaesthetics decrease inflammation without increasing the susceptibility to infections and prevent post-operative thrombotic events without increasing bleeding.

Regional anaesthesia-analgesia attenuates perioperative immunosuppression. The hypothesis that patients who receive combined propofol/paravertebral anaesthesiaanalgesia (propofol/paravertebral) exhibited reduced levels of protumorigenic cytokines and matrix metalloproteinases (MMPs) and elevated levels of antitumorigenic cytokines compared with patients receiving sevoflurane anaesthesia with opioid analgesia (sevoflurane/opioid). Regional anaesthesia-analgesia for cancer surgery alters a minority of cytokines influential in regulating perioperative cancer immunity*.* However, any reduction of immunosuppression is less expressed in regional—spinal anaesthesia. Local anaesthetics lidocaine and bupivacaine have influence on a release of IL-1 beta from human lymphocytes *in vitro* reducing chemotaxial and fagocite activity of neutrofiles and inhibits mitogen-induced proliferation of lymphocytes*.*

Both types of neuraxial anaesthesia, spinal and epidural and general anaesthesia, are associated with impulsive falls in intraoperative blood pressure. Epidural anaesthesia can be used as a sole continuous anaesthetic technique (as a perioperative analgesia and in the same time as an intra-operative anaesthesia) or as a combined

spinal-epidural anaesthesia. This regional technique provides excellent analgesia, but may limit early mobilisation after surgery.

Matot et al. in their study from 2003 [17] make a comparison of the analgesic effect of systemic versus continuous epidural analgesia in patients with hip fracture and with high cardiac risk, and came to a conclusion that the incidence of cardiac complications was higher in patients with systemic versus continuous epidural analgesia (11 from 34 patients in systemic analgesia group vs. 2 from 34 patients in group with continuous epidural analgesia). In this study, epidural catheter was placed in early preoperative period due to patients' admission. Few other studies demonstrated that perioperative analgesic management with continuous epidural analgesia started preoperatively reduced the incidence of myocardial ischemia in elderly patients with hip fractures surgery. These result due to sympatholytic effect of local anaesthetic, which in the same time relieves pain and decreases the stress response in perioperative period.

Performing epidural and spinal anaesthesia may be more difficult in elderly patients. It is often not easy to position the elderly patient appropriately in the lateral position, and frequently, these patients have degenerative changes of the spine. Spinal

(subarachnoid) anaesthesia is commonly used, with or without sedation. Conceptually spinal anaesthesia for hip fracture fixation in elderly patients should

be viewed distinctly from spinal anaesthesia for caesarean section in younger patients. Lower doses of intrathecal bupivacaine (< 10 mg) appear to reduce associated hypotension. Co-administration of intrathecal opioids prolongs post-operative analgesia; fentanyl is preferred to morphine or diamorphine, which are associated with greater respiratory and cognitive depression.

Sedation may be provided, but should be used cautiously in the very elderly. Midazolam and propofol are commonly used. Ketamine may be used, theoretically to prevent hypotension, but may be associated with post-operative confusion. Supplemental oxygen should always be provided during spinal anaesthesia.

To achieve general anaesthesia in this group of patients, reduced doses of intravenous induction agents should be administered. Inhalational induction is well tolerated by the elderly and allows for maintenance of spontaneous ventilation. There remains debate about whether mechanical ventilation is preferred to spontaneous ventilation. Paralysis and tracheal intubation are associated with greater physiological derangement than spontaneous ventilation, but proponents argue that mechanical ventilation reduces the risk of perioperative aspiration and allows greater control of arterial carbon dioxide levels. Intraoperative hypoxemia is common, and higher inspired oxygen concentrations may be required.

#### **4.4 Beneficial effects of local anaesthetics**

Local anaesthetics for spinal anaesthesia are not only used as drugs to block the sodium channel to provide analgesia and anti-arrhythmic action. Continuous infusion of local anaesthetics has been shown to be the most efficient means to control post-operative pain. Local anaesthetics are the only drugs, which can block almost all the pain pathways involved in post-operative pain. Distribution of local anaesthetics after subarachnoid injection is shown in **Figure 2**. Efficient post-operative pain will not only improve patient's well-being but also accelerate ambulation and decrease the incidence of the post-operative chronic pain syndrome. Interestingly, local anaesthetics also possess anti-inflammatory effects, which may open new indications in different medical settings. Recent research has focused on the use of i.v. local anaesthetics to improve bowel function after surgery or trauma, to protect the central *Regional Anaesthesia for Hip Surgeries DOI: http://dx.doi.org/10.5772/intechopen.104086*

#### **Figure 2.** *Application of local anaesthetics after subarachnoid injection.*

nervous system, to find new clues of local anaesthetic effect synchronic neuropathic pain and to investigate the long-term effect of anaesthesia/analgesia provided by local anaesthetics on cancer recurrence. There is growing evidence that local anaesthetics have a broad spectrum of indications aside analgesia and anti-arrhythmic effect. Most of them are still insufficiently known and investigated [18].
