"The hemodynamic stability in the elderly patients is of great importance; therefore, according to the study by Ho et al. (22) and Asao et al. (23), LPB can be suggested as the first choice in the elderly, critically ill, or hemodynamically compromised patients. Recent meta-analysis on the risk for falls after major lower extremity orthopedic surgery with LPB showed that in comparison with noncontinuous LPB or no block, continuous LPB was associated with a significant increase in the risk of falls (31). "
[Show abstract][Hide abstract] ABSTRACT: Background:Lumbar plexus block (LPB) is one of the anesthetic options in the elderly patients undergoing hip surgeries. LPB could be safe because it targets somatic nerve in psoas region. Effectiveness of LPB is attributed to the sufficient analgesia provided intraoperatively as well as postoperatively. Adequate muscle relaxation and immobility during surgery refers to its acceptability.Objectives:In this study, LPB was used as the anesthetic method to manage the elderly patients subjected to hip surgery.Patients and Methods:A total of 50 patients aged 51 to 100 years were enrolled in this study. LPB was accomplished after a mild sedation and with a modified method using patient's fingertip width (FTW) as the distance unit to determine needle entry point under electrical nerve stimulation assistance. After targeted injection, procedure time, establishment time, block duration, surgery time, hemodynamic variables, and surgeon satisfaction score were documented and analyzed. Propofol in trivial doses was infused intraoperatively to provide clinical sedation.Results:Mean patient's age was 73 ± 12 years with ASA II/III. Procedure time was 5.65 ± 1.24 minutes, establishment time was 130 ± 36 seconds, block duration was 13.1 ± 8 hours, surgery time was 149.7 ± 32.2 minutes, and surgeon satisfaction score was 9.8 ± 0.1. There was no complication and no failure. Hemodynamic stability was pleasantly achieved.Conclusions:By preserving hemodynamic stability, LPB in conjunction with a light sedation could be considered as a reliable prudent satisfying anesthetic option in management of hip fractures in the elderly patients with three beneficial characteristics of safety, effectiveness, and acceptability.
Anesthesiology and Pain Medicine 08/2014; 4(3):e19407. DOI:10.5812/aapm.19407
[Show abstract][Hide abstract] ABSTRACT: Total hip (THA) and knee arthroplasty (TKA) are common procedures in elderly persons, who are at potential increased risk of postoperative fall due to loss of muscle strength and impaired balance. Fast-track surgery with early mobilization and opioid-sparing analgesia have improved outcomes after these procedures, but early mobilization and short hospitalization length of stay (LOS) could potentially increase the risk of falls after discharge. We investigated injuries, circumstances, and the timing of fall-related hospital admissions 90 days after fasttrack THA and TKA.
This was a prospective, descriptive multicenter study on fall-related hospital admissions, in 5145 elective fast-track THA and TKA patients, with complete 90-day follow up through the Danish National Patient registry and medical charts.
Of 83 (1.6%) fall-related hospital admissions, 43 (51.8%) were treated in the Emergency Room and 40 (48.2%) were admitted to a regular ward. The median LOS after surgery was 3 days (interquartile range [IQR]: 2-3) in fallers versus (vs) 2 days (IQR: 2-3) (P=0.022) in patients without falls. Injuries were classified as "none" or minor in 39.8%, moderate in 9.6%, and major in 50.6%. Most falls (54.8%) occurred within 1 month of discharge. Falls due to physical activity (12.0%) and extrinsic factors (14.5%) occurred later than did surgery-related falls (73.5%), contributing to 40% of all falls >30 days after discharge. In multivariate analysis, age (odds ratio [OR]: 1.05; 95% confidence interval [CI]: 1.0-1.08) (P=0.001), living alone (OR: 2.09; 95% CI: 1.20-3.62) (P=0.009), and psychiatric disease (OR: 2.80; 95% CI: 1.42-5.50) (P=0.001) were associated with surgery-related falls, whereas the use of a walking aid (OR: 1.20; 95% CI: 0.67-2.16) (P=0.544) and LOS ≤4 days (OR:1.19; 95% CI: 0.52-1.28) (P=0.680) was not.
Hospital admissions due to falls are most frequent within the first month after fast-track THA and TKA. The overall incidence of surgery-related falls amongst these patients is low, declines after the first month, and is related to patient characteristics rather than short LOS. The effect of interventions aimed at surgery-related falls should focus on the first 30 days after surgery and differentiate between the causes of falling.
[Show abstract][Hide abstract] ABSTRACT: Femoral nerve block (FNB), a commonly used postoperative pain treatment after total knee arthroplasty (TKA), reduces quadriceps muscle strength essential for mobilization. In contrast, adductor canal block (ACB) is predominately a sensory nerve block. We hypothesized that ACB preserves quadriceps muscle strength as compared with FNB (primary end point) in patients after TKA. Secondary end points were effects on morphine consumption, pain, adductor muscle strength, morphine-related complications, and mobilization ability.
We performed a double-blind, randomized, controlled study of patients scheduled for TKA with spinal anesthesia. The patients were randomized to receive either a continuous ACB or an FNB via a catheter (30-mL 0.5% ropivacaine given initially, followed by a continuous infusion of 0.2% ropivacaine, 8 mL/h for 24 hours). Muscle strength was assessed with a handheld dynamometer, and we used the percentile change from baseline for comparisons. The trial was registered at clinicaltrials.gov (Identifier: NCT01470391).
We enrolled 54 patients, of which 48 were analyzed. Quadriceps strength as a percentage of baseline was significantly higher in the ACB group compared with the FNB group: (median [range]) 52% [31-71] versus 18% [4-48], (95% confidence interval, 8-41; P = 0.004). There was no difference between the groups regarding morphine consumption (P = 0.94), pain at rest (P = 0.21), pain during flexion of the knee (P = 0.16), or adductor muscle strength (P = 0.39); neither was there a difference in morphine-related adverse effects or mobilization ability (P > 0.05).
Adductor canal block preserved quadriceps muscle strength better than FNB, without a significant difference in postoperative pain.
Regional anesthesia and pain medicine 10/2013; 38(6). DOI:10.1097/AAP.0000000000000015 · 3.09 Impact Factor
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