**14. Anesthesia techniques in hip fracture operations**

#### **14.1. General anesthesia**

• It may be possible for hip fracture operations to obtain safer results with general anesthesia.


Important points in general anesthesia:

**12. Pain education**

58 Total Hip Replacement - An Overview

block.

**13. Approaches to oncological patients**

pneumonia and interstitial fibrosis due to bleomycin.

In the urinary system, radiation nephropathy can be seen.

pericarditis and congestive heart failure.

**14.1. General anesthesia**

Preoperative training including surgical procedure and rehabilitation protocol, informing the prospective benefits of the procedure, postoperative pain level and pain management techniques (intravenous, epidural patient-controlled analgesia), is beneficial to reduce patient anxieties, increase patient satisfaction, and reduce rehabilitation and hospital stay. Pre-emptive administration of opioid analgesics, NSAII and COX-2 inhibitors can provide effective postoperative analgesia. However, it should be considered that opioid use is associated with increased postoperative nausea and vomiting risk. Pre-emptive epidural analgesia with an epidural catheter prior to arthroplasty can provide postoperative pain control at a significant level [10].

Systematic evaluation of oncologic patients is important. Patients are questioned about whether they have received chemotherapy (RT) or radiotherapy (RT). In these patients, impaired health

Alkylating agents such as cyclophosphamide may cause prolongation of the neuromuscular

It should be kept in mind that oxygen therapy at high concentration increases interstitial

Skin reactions related to RT and KT should be noted. Vascular access may be problematic. Most cancer patients are malnourished due to their illnesses and side effects of treatment. Loss of appetite, cachexia, hyperproteinemia and hypoalbuminemia are common. Preoperative nutritional support should be given. Immunonutrition is thought to be useful to reduce immunosuppression. Lung metastases may be found to impair respiratory functions. The cardiotoxic effects of KT and RT may extend to cardiomyopathy, pericardial effusion,

In the hepatobiliary system, hepatomegaly, deterioration in liver function tests and even cir-

Multidisciplinary examination of cancer patients should be done. After their clinical and labo-

• It may be possible for hip fracture operations to obtain safer results with general anesthesia.

rhosis can be seen. Decrease in coagulation factors and coagulopathy can be seen.

In the hematopoietic system, immune system impairment may be seen.

ratory values are improved, the patients should be given to surgery.

**14. Anesthesia techniques in hip fracture operations**

status and blood vessel changes due to bone marrow suppression may be seen.


#### *14.1.1. The general anesthesia management in elderly patients*

Given that the vast majority of hip fracture surgeries are performed on elderly individuals, general anesthesia guidelines should be followed in geriatric patients. At first, the premedication to which the respiratory tract may be depressed should be avoided or the dose should be reduced.

When performing volume replacement, the cardiac load should be avoided and the mean arterial pressure should be preserved. Respiratory depression can be avoided by minimizing the opioid dose. The inotropic medicines can be necessary to treat hypotension. The preserve of renal function should also be supplied.

We must make sure that the neuromuscular block is completely turned. For postoperative analgesia, regional anesthesia techniques should be used and the dose should be adjusted.

#### **14.2. Regional anesthesia**

There is a long history for epidural and spinal block interventions and the use of these interventions for pain relief. Both techniques are widely used around the world. They have some advantages such as regional anesthesia interventions, early mobilization, postoperative pain relief and reduced risk of DVT, hypoxia and conscious problems [12]. There are a number of studies in geriatric patients that indicate the superiority of regional anesthesia in hip fracture operations.

Advantages of spinal anesthesia:


#### Disadvantages:


• It provides longer analgesia with opioids and/or local anesthetics even in postoperative

Anesthesia Management in Total Hip Replacement http://dx.doi.org/10.5772/intechopen.76366 61

• The incidence of headache due to postdural puncture is low, and it also provides autogenous blood injection to treat/protect headache due to incidental postdural puncture.

If neuro-axial blockage is contraindicated, fascia iliaca block, femoral nerve block and sciatic nerve block can be applied. Peripheral nerve blockage is particularly useful in tumor patients

Lumbosacral blocks and femoral and sciatic nerve blocks may be used in hip arthroplasty operations in geriatric patients. These blocks also provide postoperative pain treatment. Since peripheral nerve blocks do not have sympathetic blockade, sudden hypotension cannot occur.

• The use of Stimuplex may not be needed, the number of punches is reduced, the dose is reduced, and the blockage application time is reduced. Vasculature may not be prevented, the duration of the blockage is not prolonged in adults, and the shortened neuropraxia

Decent postoperative evaluation and care after the surgery are important factors for the healing of the patient. Post-anesthetic care includes periodic follow-up, if necessary; the treatment of respiratory, cardiovascular and neuromuscular functions of the patient; and monitoring of blood level, body temperature, pain intensity, nausea, vomiting, drainage, bleeding and

**The respiratory system** is followed by the pulse oximeter monitoring. It is useful for early detection of hypoxia. ASA recommends oxygen supplementation therapy at risk of hypoxemia, during transport and at collection facilities. Oxygen therapy for up to 24 hours is especially recommended in the elderly group at risk of myocardial ischemia undergoing the hip

period.

Advantages:

**14.3. Peripheral nerve blockage**

developing opioid intolerance and using anticoagulants.

• Higher possibility of providing unilateral blockage.

• The effect of them on central nervous system is minimal.

• Less sympathetic blockade than regional techniques.

**14.4. Evaluation after operation in hip fracture surgery**

The use of ultrasonography in peripheral blockage:

• The respiratory system is not affected.

does not decrease [14].

urinary output.

fracture surgery.

• Protection of the patient's consciousness and unaffected respiration.


Advantages of epidural anesthesia:


Combined spinal-epidural anesthesia:


### **14.3. Peripheral nerve blockage**

If neuro-axial blockage is contraindicated, fascia iliaca block, femoral nerve block and sciatic nerve block can be applied. Peripheral nerve blockage is particularly useful in tumor patients developing opioid intolerance and using anticoagulants.

Lumbosacral blocks and femoral and sciatic nerve blocks may be used in hip arthroplasty operations in geriatric patients. These blocks also provide postoperative pain treatment. Since peripheral nerve blocks do not have sympathetic blockade, sudden hypotension cannot occur.

Advantages:

• Short acting time

• Cost-effective

Disadvantages:

• Easy to perform

• Rarely shaking.

• No headache.

• The effect time is long.

• High dose is required.

• Shaking is often present.

Combined spinal-epidural anesthesia:

extremity surgery and birth analgesia.

• More effective analgesia

60 Total Hip Replacement - An Overview

• Provide better muscular relaxant effect

• Rarely serious respiratory depression

• Provide low dose and toxicity.

Advantages of epidural anesthesia:

• Hypotension is more frequent and sudden onset.

• Upper level of blockage may be changed and cannot be adjusted.

• The desired block level can be titrated with the catheter.

• The depth of the block may vary depending on the agent. • Lower boundary may vary; sacral distribution is limited.

• It is possible to complete an inadequate spinal anesthesia.

• It provides both spinal and epidural advantages as mentioned above in abdominal, lower

• It is possible to obtain postoperative analgesia [13].

• The duration of anesthesia can be extended with added doses.

• The incidence of post-spinal headache is high.

• Postoperative analgesia cannot be obtained. • Duration of the effect cannot be extended.


The use of ultrasonography in peripheral blockage:

• The use of Stimuplex may not be needed, the number of punches is reduced, the dose is reduced, and the blockage application time is reduced. Vasculature may not be prevented, the duration of the blockage is not prolonged in adults, and the shortened neuropraxia does not decrease [14].

#### **14.4. Evaluation after operation in hip fracture surgery**

Decent postoperative evaluation and care after the surgery are important factors for the healing of the patient. Post-anesthetic care includes periodic follow-up, if necessary; the treatment of respiratory, cardiovascular and neuromuscular functions of the patient; and monitoring of blood level, body temperature, pain intensity, nausea, vomiting, drainage, bleeding and urinary output.

**The respiratory system** is followed by the pulse oximeter monitoring. It is useful for early detection of hypoxia. ASA recommends oxygen supplementation therapy at risk of hypoxemia, during transport and at collection facilities. Oxygen therapy for up to 24 hours is especially recommended in the elderly group at risk of myocardial ischemia undergoing the hip fracture surgery.

**Cardiovascular system:** ECG and blood pressure monitor should be continued during waking and compilation. It should not be forgotten that arthroplasty patients are elderly and cardiovascular comorbid diseases can be found and the risk of postoperative cardiac complications is high. The most important factor affecting mortality in geriatric patients is the current co-morbidities. Increase in troponin I is important in postoperative follow-up due to myocardial ischemia.

Bupivacaine and opioid protocols. are mostly used in regionalized PCA. It should be noted

Anesthesia Management in Total Hip Replacement http://dx.doi.org/10.5772/intechopen.76366 63

**Periarticular injection** and multimodality in patients with hip arthroplasty should be part of the treatment [16]. Periarticular injection solution includes; bupivacaine 0.5% 200–400 mg, morphine sulfate 4–10 mg, epinephrine 300 mcg, methylprednisolone 40 mg, cefuroxime 750 mg

Periarticular injection is applied in anterior capsule, iliopsoas tendon and inseriosion before reduction. After reduction,it is applied in abductor, fascia lata, snovia, gluteus maximus and

**Duration of hospital stay and ambulance**: The average length of hospital stay is 3 days in hip arthroplasty. After a hip fracture repair, the average time for elderly patients is 20 days. Although there are many studies advocating that neuro-axial anesthesia is an advantage in

[1] Patterson BM, Healy JV, Cornell CN, et al. Cardiac arrest during hip arthroplasty with a cemented long-stem component. The Journal of Bone and Joint Surgery. American

[2] Ranawat CS, Beaver WB, Sharrock NE, et al: Effect of hypotensive epidural anesthesia on acetabular cement-bone fixation in total hip arthroplasty. The Journal of Bone and Joint

[3] Thompson GE, Miller RD, Stewans WC, Murray WR. Hypotensive anesthesia for total hip arthroplasty: A study of blood loss and organ function (brain, heart, liver and kid-

[4] Vazeery AK, Lunde O. Controlled hypotension in hip joint surgery: An assessment of surgical haemorrhage during sodium nitroprusside infusion. Acta Orthopaedica

[5] Weber RS et al. Anemia and transfusions in patients undergoing surgery for cancer.

ambulance [17], there are studies advocating that the anesthesia route is not effective.

that opioids administered by the epidural route may also cause sedation.

and 0.9% NaCl. The total volume is 60 ml.

**Author details**

Guldeniz Argun

**References**

Volume. 1991;**73A**:271

Surgery. British Volume 1991;**73B**:779

Annals of Surgical Oncology. 2008;**15**:34-35

ney). Anesthesiology. 1978;**48**:91

Scandinavica. 1979;**50**:433

insercius, posterior capsules, short external rotators.

Address all correspondence to: guldargun@yahoo.com

Departmant of Anesthesiology and Reanimation, Ankara, Turkey

**Assessment of neuromuscular functions (NMF)** is done by physical examination and neuromuscular block monitors.

**Body heat:** Preservation of normothermia and periodic body temperature measurements should be made to prevent hypothermia, and heaters should be used if necessary. Both anesthesia recovery and postoperative patient comfort are important. In the treatment of thyroid disease, agents such as low-dose meperidine and tramadol can also be used.

**Thromboemboli:** Prophylactic anticoagulants, early mobilization, intermittent pneumatic compression devices, compression socks and neuro-axial anesthesia can reduce thromboembolic complications. Continuation of acetyl salicylic acid therapy is recommended in elderly patients. The use of regional anesthesia and anticoagulation is still controversial.

**Nausea and vomiting**: Periodic control of nausea and vomiting is important to detect complications. In the treatment of nausea and vomiting, 5-HT3 antagonists, tranquilizers/neuroleptics, scopolamine, dexamethasone, antihistamines or metoclopramide may be used.

**Renal functions:** Urinary retention is a common complication. It is especially more common after epidural anesthesia. This complication does not occur in peripheral nerve blocks.

**Cognitive changes**: Cognitive changes after hip fracture operations are common in elderly patients. There are studies showing that short-term cognitive changes are less frequent after spinal anesthesia. However, there was no difference in the long term.
