American Society of Regional Anesthesia and Pain Medicine August 2016 - 11

also for surgery. The ability to meet family and discuss anesthesia
before the day of surgery seems to optimize our relationship with
family and gives us an opportunity to provide guidance on how to
optimize the patients medically. If we identify issues that need to
be resolved before surgery, the patient can be fed and not held NPO
for extended periods of time unnecessarily.

HEALTH PREVENTION QUESTIONS TO DISCUSS WITH ALL
ELDERLY PATIENTS AND THEIR FAMILIES.
Have you been checked for osteoporosis?
Have you had your eyes checked recently?

Generally, all hospitals attempt to minimize the time from admission
to the time of surgery as best practice in hip fracture care. Despite
that effort, the sickest patients may have a prolonged wait time
before surgery. This is the most vulnerable group of patients but
also the group that likely achieves the most benefit from this pain
pathway.
At arrival in the preoperative holding area before surgery, a bolus of
local anesthetic is delivered through the catheter before anything
else is done. The bolus of local anesthetic deepens the block and
permits more comfort for the patient before placement on his or her
side for spinal anesthesia.
At surgery, spinal anesthesia is used wherever possible.
Ultrasonography can prove very helpful in elderly patients to
assist with spinal placement. The authors have found L5-S1
space using ultrasonography many times where other colleagues
have struggled to place a spinal. Careful dose reduction in spinal
anesthesia is important in elderly patients (5-7.5 mg). A recent
article examined the minimal doses of spinal local anesthetic
for hip fracture when using titration via a spinal catheter.2 Using
the Dixon Massey method, the authors found that doses as low
as 0.24 mL of 0.5% isobaric bupivacaine may be all that is
required initially. The cumulative dose was just over 1 mL of 0.5%
isobaric bupivacaine. This dose is much lower than is normally
given by most practitioners. With their low dose, they found less
hypotension than previously reported with larger doses of local
anesthetic.
As part of the time-out at surgery, a discussion should occur
about keeping the peripheral nerve catheter or pulling it. The
catheter should be pulled in the operating room if there is a
realistic expectation that the patient will ambulate on the day
of surgery. If the patient is very frail and was not ambulating
independently before surgery or is not likely to ambulate the
day of surgery, consider keeping the catheter running for
postoperative analgesia.

Do you take exercise for strength and balance (eg, Tai Chi)?
Have you made your home safer (eg, hand rails, proper
lighting, avoiding trip/fall accidents)?

One issue that has come up on occasion is our inability to always
immediately attend to these patients in the ER as soon as we
are called. Since this is covered by the on-call team, sometimes
emergencies require the team members to delay placement of a
catheter until their emergent obligations lessen. This has occurred
a very small number of times but can happen when using this
model of staff coverage. With the initiation of this program, we also
had to determine how to accurately and reliably mark the fracture
site and block side before placing the nerve block. Typically, the
surgeon must mark the site before block placement when in an
operative setting. In this case, it is unlikely to be marked, as the
patient is in the ER and not in preoperative holding. A discussion of
how to manage this must take place, and your team must have a
systematic way to address this issue. In our institution, we chose
to have a member of the ER nursing team present for the time-out
before block placement. The site marking is done as part of the
multidisciplinary team time-out.
A continuous peripheral nerve catheter program for hospital
admissions for a fractured neck of femur is patient-centered
care at its most rewarding. This frail and vulnerable patient
population can greatly benefit from the regional analgesia expertise
anesthesiologists can provide.
REFERENCES
1.

Riddell M, Ospina M, Holroyd-Leduc JM. Use of femoral nerve blocks to manage
hip fracture pain among older adults in the emergency department: a systematic
review. CJEM 2015;1-8. doi:10.1017/cem.2015.94.

2.

Szucs S, Rauf J, Iohom G, Shorten GD. Determination of the minimum initial
intrathecal dose of isobaric 0.5% bupivacaine for the surgical repair of a
proximal femoral fracture: a prospective, observational trial. Eur J Anaesthesiol
2015;32:759-763.

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2016

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