2.  Why this topic?
 Why choose this topic?
 General information
 Regional anaesthesia and its modes of usage
 Common anaesthetic agents used
 How do the anaesthetics work
 Comparing the side effects of the different types of
anaesthesia
 Differences seen and their likely explanation
 Comparison mortality rates
 Cochrane evidence
 Patient’s perspectives
 Anaesthetist’s perspectives
 References

3.  Hip fracture management forms large bulk of work in
orthopaedics
 Prediction to be 6.3 million cases globally by 2050, Approx
80,000 per year in UK (65,000 in over 65’s)
 Anaesthesia is of prime importance in the active management
 Mainly affects the elderly female population with intercurrent
illnesses- importance of the appropriate anaesthesia

4. ‘Anaesthesia aims to ensure hypnosis, amnesia,
analgesia, relaxation of skeletal muscles with loss
of control of reflexes of the autonomic nervous
system’

5.  Regional anaesthesia
 Applicable large parts of the body
 Divided into central and peripheral
 Neuraxial blocks – epidural anaesthesia and spinal
anaesthesia
 Peripheral - plexus blocks and single nerve blocks
 Regional anaesthesia- spinal injection of LA or
epidural , often used with sedatives
 GA induced and maintained by a number of drugs-
dependent on the anaesthetist preference with
appropriate airway

6. Epidural Spinal

7. Comparing psoas compartment catheter and epidural catheter
Psoas compartment catheter Epidural catheter

8.  Spinal anaesthesia in hip surgery-
lidocaine, mepivacaine, bupivacaine, ropivacaine, tetravacaine
 Lumbar epidural anaesthesia in hip surgery –
2- Chloprocaine, lidocaine, etidocaine, mepivacaine, bupivacaine,
ropivacaine
 General anaesthetic –
with inhalational, intravenous anaesthetic agents

9.  Reversible interruption of the conduction of impulses in peripheral
nerves
 Blockade of Sodium channels- impairing sodium flux across the
membrane, to some extent on Potassium channels also
 Main effect – local decrease in rate and degree of depolarisation-
threshold potential not reached and electrical impulse not
propagated
 No effect on the resting or threshold potential, however refractory
period and repolarisation may be prolonged.

11.  The exact mechanism is not known despite
of its usage for more than 150 yrs.
 Structure is related to ether, the original
anaesthetic
 Primary site of action is on the CNS- inhibit
nerve transmission- reduction in nerve
transmission at the synapses
 Potentiated by 2 main receptors;
 GABA-A- Potentiated by halothane,
etomidate and propofol
 NMDA- inhibited by ketamine
 Inhalation anaesthetics e.g. sevoflurane-
main action on brain

12.  Epidural
 Hypotension- commonest side effect, esp imp for cardio problems
 High epidural block- unintentional
 Local anaesthetic toxicity- another unintentional side effect
 Regional anaesthesia- impaired coagulation or poor patient cooperation
 Rarely becomes a fully spinal anaesthetic
 Spinal
 Length of surgery
 Headache- commonest complaint amongst young patients
 Rarely- infection
 General Anaesthesia
 Usually well tolerated
 Rarely can lead to stroke or myocardial infarction
 Aspiration – prevented by endotracheal tube insertion

13.  Meta-analysis by Urwin S.C et al.
 Previous meta-analysis of 11 trials showed no overall
advantages in one anaesthetic over the other
 In terms of risk of DVT and survival at one month- Regional
better than General anaesthesia
 Results not applicable to all settings due to underlying
morbidity not being considered

14.  Risk of DVT
 Risk of intraoperative hypotension – no significant reduction
with either method
 Risk of pulmonary embolism(fatal and non-fatal)- reduced
incidence of fatal PE and major thromboembolism with
regional
 Risk of other conditions- pneumonia, urinary retention,CCF,
post-operative vomiting and nausea- no significant
differences seen

15.  Spinal group risk of DVT – 30% GA group- 47%
 N.B- venography was used in the cases in which patients had
DVT
 Reduced sympathetic tone to the lower limbs with increased
venous blood flow
 Alteration in viscosity and coagulability of blood- regional
anaesthesia

16.  GA associated with small but significant reduction in the
length of the operation
 Non-significant tendency for greater confusion following GA
 Reduced tendency of CVA after GA is due to a more stable
perioperative blood pressure
 IV therapy+ vasoconstrictor agents during regional
anaesthesia could reduce the adv of GA
 Regional anaesthesia has marginal advantages

17.  Mortality - important post-operative concerns
 Flawed methodology in studies included in Cochrane analysis
 Valentin et al.- 1968 prospective study looking at the mortality
of 578 patients post-op repair of NOF
 30 days after surgery the mortality was 6% -spinal and
8%- general anaesthesia
 6months to 2 years post-op- the mortality was identical
 No differences with respect to ambulation and discharge

18.  Estimated blood loss was smaller (P < 0.05) in patients
receiving spinal anaesthesia
 high short-term mortality was related to age, male sex, and
trochanteric fracture
 long-term mortality was related to male sex and high ASA
scores.

19.  Cochrane analysis done in 2009
 Primary outcome was mortality
 8 trials decreased mortality at one month with regional
anaesthesia 6.9% vs. 10.0% with general anaesthesia
 Reduced risk of DVT; Regional (30%) versus general (47%)
 Regional assoc with reduced risk of acute postoperative
confusion 9.4 % vs. 19.2 %
 Flawed methodology- biased sample of patients

20.  Awareness is of the main concern that patients have
 Mashour et al. 2009 – no statistical difference in intraoperative
awareness
 Intraoperative awareness complaints in GA 0.023% vs. Regional
anaesthesia 0.03%
 Complete unconsciousness is often the expectation of the
patient
 Often the communication between anaesthetist and patient is
seen to be inadequate in patient’s experience
 Rehabilitation is often seen to be quicker with regional
anaesthesia when compared with general anaesthesia

21. ‘One of the hardest anaesthetic lists to do’- CT2 Anaesthetist
The main reason being the comorbidities present in the patients
This makes monitoring of the patient challenging
The final decision is up to to the anaesthetist in terms of the route of
administration
Donati et al. BJA 2004 - operative risk of 4000 patients.
The risk for ASA (American Society of Anaesthesiologists) 4 ,
Age>70,
Elective surgery was 3.7 %
Urgent/emergency it was as high as 16.7%

22.  There are various methods of anaesthesia for
the repair of hip fracture
 Better trials with the unbiased sample, and
better follow up is needed
 Various factors determine the chosen method-
patient, anaesthetist and surgeon
 All aim for early patient mobilisation
following operation

23. 1. Melton Hip fractures; a worldwide problem today and tomorrow Bone
1993;14 (Suppl. 1): S1-8
2. General versus regional anaesthesia for hip fracture surgery: British
Journal of Anaesthesia 84 (4): 450–5 (2000).
3. Mashour GA, Wang L, Turner CR, Vandervest JC, Shanks A, Tremper KK.
A retrospective study of intraoperative awareness with methodological
implications. Anesth Analg 2009;108:521–6
4. N. Valentin, M.D.,B. Lomholt, M.D., J. S. Jensen, DR MED. SC., N.
Hejgaard M.D. and S. Kreiner, Cand. Stat. Spinal or General
Anaesthesia for surgery of the fractured hip? A Prospective Study of
Mortality in 578 Patients. Br. J. Anaesth. (1986)
5. Dr K Balakrishnan ; Care of the patient with fracture neck of femur for
non-emergency surgery.