Author details

Bharati Rajdev\* and Subash Sivasubramaniam

\*Address all correspondence to: bharati.rajdev@nhs.net

Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom

### References

[1] National Institute for Health and Clinical Excellence. The Management of Hip Fracture in Adults. 2011. http://www.nice.org.uk/nicemedia/live/13489/54918/54918.pdf

[2] Association of Anaesthetists of Great Britain and Ireland. Management of proximal femoral fractures 2011. Anaesthesia. 2012;67:85-98

4.1. Postoperative cognitive dysfunction

46 Total Hip Replacement - An Overview

with reduced morbidity and mortality.

Bharati Rajdev\* and Subash Sivasubramaniam

\*Address all correspondence to: bharati.rajdev@nhs.net

5. Conclusions

mortality.

care pathways

anaesthetists.

Conflict of interest

None declared.

Author details

References

This is common in this group of patients. Management includes adequate analgesia, nutrition and hydration, electrolyte balance, appropriate medication, optimising bowel habit, mobilisation and also identifying and treating any infection or silent myocardial ischaemia. Drugs such as

1. Patients with a hip fracture have a relatively high risk of perioperative morbidity and

2. High-quality care of these patients requires multidisciplinary care and protocol-driven

3. Early surgery aids in providing analgesia and allows early mobilisation, and is associated

4. The mode of anaesthesia provided is less important than the manner with which it is delivered with regard to the age and pathophysiological status of the individual patient.

5. Surgery and anaesthesia must be undertaken by appropriately experienced surgeons and

Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom

Adults. 2011. http://www.nice.org.uk/nicemedia/live/13489/54918/54918.pdf

[1] National Institute for Health and Clinical Excellence. The Management of Hip Fracture in

haloperidol or lorazepam should only be used for short-term control of symptoms.


[16] Neuman MD, Rosenbaum PR, Ludwig JM, Zubizarreta JR, Silber JH. Anesthesia technique, mortality, and length of stay after hip fracture surgery. Journal of the American Medical Association. 2014;311:2508-2517

**Chapter 4**

**Provisional chapter**

**Anesthesia Management in Total Hip Replacement**

Hip fracture is usually seen in advanced age. Due to the presence of metastases in elderly patients, the density of bones decreases, and the possibility of fracture increases. Cytokines, released from osteoclasts resulting in post-bony destruction, cause pain by activating pain receptors; hence, pain-related motion restriction may occur. Bone marrow suppression and medulla spinalis pressure may be seen in metastatic bone tumors. Three major complications can be observed in hip fracture operations: (1) perioperative bleeding, (2) bone cementum implantation syndrome and (3) thromboembolism. These indicate superiority of general anesthesia: 1 –controlled respiration. 2 –Invasive interventions to be performed during shock treatment can be made more easily and smoothly. 3 – The safest way to ensure that patients remain immobilized on the operating table. 4 – Hemodynamic parameters can be better controlled. Regional anesthesia has benefits such as allowing early mobilization and postoperative pain control and few complications such as hypoxia, deep vein thrombosis and consciousness blurring. Various regional anesthesia methods such as spinal, epidural, combined spinal-epidural and peripheral nerve blocks are applied. The knowledge and experience of the anesthetist, the general condition and the mental state of the patient, the skill of the surgeon and the type of sur-

Hip fracture is an important medical problem, which is seen in elderly patients, and has a higher incidence related to increased life expectancy, causing increased economic burden. Substantial increase of hip fractures is seen due to increased incidence of age-related osteoporosis and decreased balance resulted in falling. Fractures are more common in women, since osteoporosis is seen frequently in women. About 15–30% of patients with hip fracture

**Anesthesia Management in Total Hip Replacement**

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.76366

Guldeniz Argun

Guldeniz Argun

**Abstract**

**1. Introduction**

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

gery determine the type of the anesthesia.

**Keywords:** hip fracture, regional anesthesia, general anesthesia

http://dx.doi.org/10.5772/intechopen.76366


#### **Anesthesia Management in Total Hip Replacement Anesthesia Management in Total Hip Replacement**

DOI: 10.5772/intechopen.76366

#### Guldeniz Argun Guldeniz Argun

[16] Neuman MD, Rosenbaum PR, Ludwig JM, Zubizarreta JR, Silber JH. Anesthesia technique, mortality, and length of stay after hip fracture surgery. Journal of the American

[17] Patorno E, Neuman MD, Schneeweiss S, Mogun H, Bateman BT. Comparative safety of anesthetic type for hip fracture surgery in adults: Retrospective cohort study. British

[18] Wood RJ, White SM. Anaesthesia for 1131 patients undergoing proximal femoral fracture repair: A retrospective, observational study of effects on blood pressure, fluid administra-

[19] Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: Randomised controlled trial.

[20] Sadeghi M, Mehr-Aein A. Does a single bolus dose of tranexamic acid reduce blood loss and transfusion requirements during hip fracture surgery? A prospective randomized

[21] Emara WM, Moez KK, Elkhouly AH. Topical versus intravenous tranexamic acid as a blood conservation intervention for reduction of post-operative bleeding in hemiarthroplasty.

[22] Zufferey PJ, Miquet M, Quenet S, et al. Tranexamic acid in hip fracture surgery: A randomized controlled trial. British Journal of Anaesthesia. 2010;104:23-30. DOI: 10.1093/bja/

[23] Lee C, Freeman R, Edmondson M, et al. The efficacy of tranexamic acid in hip hemiarthroplasty surgery: An observational cohort study. Injury. 2015;46:1978-1982. DOI: 10.1016/

[24] Vijay BS, Bedi V, Mitra S, et al. Role of tranexamic acid in reducing postoperative blood loss and transfusion requirement in patients undergoing hip and femoral surgeries. Saudi

[25] Gausden EB, Garner MR, Warner SJ, et al. Tranexamic acid in hip fracture patients: A protocol for a randomised, placebo controlled trial on the efficacy of tranexamic acid in reducing blood loss in hip fracture patients. BMJ Open. 2016;6:e010676. DOI: 10.1136/

[26] Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syn-

[27] Association of Anaesthetists of Great Britain and Ireland. Safety guideline: Reducing the risk from cemented hemiarthroplasty for hip fracture 2015. Anaesthesia. 2015;70:623-626

[28] Nagra et al. An analysis of postoperative hemoglobin levels in patients with a fractured neck of femur. Acta Orthopaedica et Traumatologica Turcica. October 2016;50(5):507-513

Journal of Anaesthesia. 2013;7:29-32. DOI: 10.4103/1658-354X.109803

drome. British Journal of Anaesthesia. 2009;102:12-22

double blind study in 67 patients. Acta Medica Iranica. 2007;45:437-442

tion and perioperative anaemia. Anaesthesia. 2011;66:1017-1022

Medical Association. 2014;311:2508-2517

British Medical Journal. 1997;315:909-912

Anesthesia, Essays and Researches. 2014;8:48-53

aep314

j.injury.2015.06.039

bmjopen-2015-010676

Medical Journal. 2014;348:g4022

48 Total Hip Replacement - An Overview

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76366

#### **Abstract**

Hip fracture is usually seen in advanced age. Due to the presence of metastases in elderly patients, the density of bones decreases, and the possibility of fracture increases. Cytokines, released from osteoclasts resulting in post-bony destruction, cause pain by activating pain receptors; hence, pain-related motion restriction may occur. Bone marrow suppression and medulla spinalis pressure may be seen in metastatic bone tumors. Three major complications can be observed in hip fracture operations: (1) perioperative bleeding, (2) bone cementum implantation syndrome and (3) thromboembolism. These indicate superiority of general anesthesia: 1 –controlled respiration. 2 –Invasive interventions to be performed during shock treatment can be made more easily and smoothly. 3 – The safest way to ensure that patients remain immobilized on the operating table. 4 – Hemodynamic parameters can be better controlled. Regional anesthesia has benefits such as allowing early mobilization and postoperative pain control and few complications such as hypoxia, deep vein thrombosis and consciousness blurring. Various regional anesthesia methods such as spinal, epidural, combined spinal-epidural and peripheral nerve blocks are applied. The knowledge and experience of the anesthetist, the general condition and the mental state of the patient, the skill of the surgeon and the type of surgery determine the type of the anesthesia.

**Keywords:** hip fracture, regional anesthesia, general anesthesia

### **1. Introduction**

Hip fracture is an important medical problem, which is seen in elderly patients, and has a higher incidence related to increased life expectancy, causing increased economic burden. Substantial increase of hip fractures is seen due to increased incidence of age-related osteoporosis and decreased balance resulted in falling. Fractures are more common in women, since osteoporosis is seen frequently in women. About 15–30% of patients with hip fracture

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

die in a year. In addition to osteoporosis, hip fractures due to bone metastases are too high to be neglected. Current treatment is to provide patient weight bearing as soon as possible. Hemiarthroplasties and locked hip nails are the first surgical treatment methods [1].

residual methyl methacrylate monomers cause vasodilatation and reduce systemic vascular resistance. Release of tissue thromboplastin triggers platelet aggregation that leads to micro thrombus formation in the lungs and cardiovascular instability due to vasoactive substances

Anesthesia Management in Total Hip Replacement http://dx.doi.org/10.5772/intechopen.76366 51

Clinical signs of complication related to bone cement are as follows:

• Pulmonary hypertension (increased pulmonary vascular resistance).

• Embolism most commonly occurs when a femoral prosthesis is placed.

• Increasing oxygen concentration in inspiration before cement procedures

• Cleaning the femoral shaft with high-pressure lavage to remove debris

Hip surgery is an operation causing significantly blood loss. Average loss of blood is about

• Some studies have shown that loss of blood in regional techniques (spinal and epidural) providing equal average blood pressure was 30–50% less than general anesthesia [3, 4]. • For bleeding control, preoperative embolization, autologous and allogeneic transfusions and hemodilution methods may be applied. Aprotinin, epsilon aminocaproic acid and

tranexamic acid prevent blood loss without increasing thrombus formation risk [5].

1000–1500 ml. Bleeding cause depends on several factors. These factors are as follows:

• Hypoxia (increased pulmonary shunt).

• Arrhythmia (including heart block and sinus arrest).

Methods to reduce cement-related complications:

• Close monitoring of the patient's fluid balance

• The surgical technique and the type of prosthesis.

• Controlled hypotension may reduce intraoperative bleeding.

• Using prosthesis without cement

• Experience of the surgeon.

**3. Bleeding**

• Opening a hole in the distal region of the femur (vent hole)

in circulation [2].

• Hypotension.

• Reduced cardiac output.

The most common problems faced in clinical practice are as follows:


Non-surgical treatment is only available to patients with poor general conditions that are too low to tolerate any of the anesthetic methods. Hip fracture treatment requires a treatment choice, which needs to be individualized at the highest level. The choice of treatment should be based on surgeon, type of fracture, patient's age and health status. In an elderly patient population, hip fractures due to falling are among the first causes of death. An important factor determining the mortality in these surgeries is an advanced age; 30% of these cases are above 85 years of age.

Complications due to hip fracture operations:

