General or neuraxial in the hip fractured patient? I choose the third option.

Dear Sir,

Hip fracture in the elder patient is a relatively common procedure that is expected to surpass the 6 million cases worldwide per year by the 2050. The higher mean age of the patients due to increased life expectancy brings also higher incidence of comorbidities.

It is not uncommon that these patients are on anticoagulant/platelet therapy with the impossibility of an adequate drug suspension timing for neuraxial anesthesia (NA). Since mortality of the hip fractured patients increases along with surgery delay, this is the reason why most of these cases are performed under general anesthesia (GA).[1] To date, there is still no high-quality evidence to recommend NA over GA or vice versa,[2] but it is known that both techniques may lead to hemodynamic instability in the fragile patient.[3]

Peripheral nerve blocks may come handy as perioperative analgesia: the most performed are the fascia iliaca compartment block, femoral nerve block, and the lumbar plexus/psoas compartment block. However, the latter shares the same limitations as the neuraxial block in the patient on anticoagulants.[45]

Despite in literature there are no reports of patients with femur fracture undergoing internal fixation under peripheral nerve blocks only, that does not exclude a third option whereas neither NB or GA are performed.

The hip joint is innervated by the femoral, obturator, and sciatic nerve. They also provide innervation to the whole leg, except the lateral leg surface innervated by the lateral femoral cutaneous nerve.

In our institution, we perform these four blocks along with deep sedation when internal fixation has to be performed in the patient on anticoagulants.

In the operating theater, a premedication with fentanyl 50 μg and midazolam 1 mg (if necessary) is administered first. The local anesthetic (LA) consisting in a 1:1 mixture of 2% mepivacaine plus 0.75% ropivacaine is prepared.

The blocks are performed under ultrasound guidance and electroneurostimulation, in this order:

Proximal femoral nerve block or fascia iliaca block (15 mL of LA)

Proximal obturator nerve block (8 mL of LA)

Lateral femoral cutaneous nerve block (2 mL of LA)

This usually provides enough analgesia to allow the patient to be turned on the lateral decubitus and perform the fourth block:

Posterior, parasacral sciatic nerve block (15 mL of LA).

During the surgery, a light sedation is usually administered with midazolam, or propofol TCI.

In our experience, this technique allows adequate anesthesia for the surgery, hemodinamic stability, prolonged postoperative analgesia, and no need for bladder catheterization. However, the blocks need to be mastered by the anesthesiologist first, and the anesthetic procedure usually takes more time than the GA or NA. On the contrary, they can be performed in the patient on anticoagulants, where NA is contraindicated, and could be a viable alternative when also GA should be avoided.

In conclusion, we expect clinical trials to confirm peripheral blockade as a valid third option for hip fractured patient management, or maybe the first.

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