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Abstract
Background and Aims Hip fracture represents a frequent cause of disability in the elderly [1]. Early surgery (<48h) has been proven to be associated with lower risk of mortality and morbidity [2]. Regional anaesthesia seems to be the best option, but there is no consensus when a central block is not indicated [3]. We present a case of a multimorbidity patient under anticoagulant drug, underwent hip fracture surgical repair with peripheral nerve blocks.
Methods Female 84 y.o. Atrial fibrillation, PMK wearer, hypertension, renal failure, CODP, cerebrovascular disease, OSAS, confusion and psychomotor agitation.
Echocardiogram: severe systolic function reduction, estimated election fraction 23%.
Right sub-capital hip fracture, candidates for hip endoprosthesis.
Anticoagulant therapy with apixaban with no data on last assumption; thromboelastogram showed augmented values, so a central block was not indicated. Patient’s multimorbidity highly elevated the risk of general anaesthesia.
With patient consent, peripheral blocks and sedation were considered. Ultrasound guided Pericapsular Nerve Group Block (PENG) was performed (ropivacaine 0,5% 20 ml + dexamethasone 4 mg), to block femoral, obturator and accessory obturator nerves, which innervate the hip [4]. Lateral femoral cutaneous nerve was also blocked, to cover surgical incision. Moderate sedation was given, maintaining spontaneous breath.
Results Surgical procedure was carried out uneventfully and without pain, parameters were good and stable during and after surgery.
FA=femoral artery; IPM=iliopsoas muscle; IPT=ilipsoas tendon; N=needle; IPE=iliopubic eminence; AIIS=anterior inferior iliac spine.
Conclusions Regional anaesthesia could be the key in fragile patients. Knowledge of anatomy and different techniques is fundamental to tailor the anaesthetic plan on patient conditions and surgical approaches.