Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2018.04.001
Brazilian Journal of Anesthesiology
Scientific Article

Perioperative lumbar plexus block and cardiac ischemia in patients with hip fracture: randomized clinical trial

Bloqueio perioperatório do plexo lombar e isquemia cardíaca em pacientes com fratura de quadril: ensaio clínico randomizado

Fernando R. Altermatt; Ghislaine C. Echevarría; René F. De la Fuente; Ricardo Baeza; Marcela Ferrada; Juan C. De la Cuadra; Marcia A. Corvetto

http://dx.doi.org/10.1016/j.bjane.2018.04.001 Braz J Anesthesiol, vol.68, n5, p.484-491, 2018
PDF English
PDF Português
Downloads: 0
Views: 608

Abstract

Abstract Background Perioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject. Methods Patients older than 60 years, ASA II–III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient-controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST-segment Holter monitoring. Results Thirty-one patients (intravenous patient-controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient-controlled analgesia group. This difference was not statistically significant (p = 0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient-controlled analgesia group) or in terms of pain scores. Conclusions Using continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Keywords

Hip fracture, Analgesia, Lumbar plexus block, Cardiovascular complications

Resumo

Resumo Justificativa A isquemia miocárdica perioperatória é comum em pacientes submetidos à cirurgia de fratura de quadril. Nosso objetivo foi avaliar a eficácia do bloqueio perioperatório contínuo do plexo lombar na redução do risco de eventos cardíacos isquêmicos em pacientes idosos submetidos à cirurgia para fraturas de quadril, expresso como uma redução de eventos isquêmicos por indivíduo. Métodos Pacientes com mais de 60 anos de idade, ASA II–III com fatores de risco para ou com doença coronariana conhecida foram incluídos neste estudo controlado e randomizado. Os pacientes foram aleatorizados para analgesia convencional usando analgésicos opioides para administração de analgesia intravenosa controlada pelo paciente (Intravenous Patient-Controlled Analgesia – IVPCA) ou analgesia contínua com o bloqueio do Plexo Lombar (PL), ambas iniciadas no pré-operatório e mantidas até o terceiro dia de pós-operatório. Monitoração contínua de ECG com análise do segmento ST foi registrada. Enzimas cardíacas seriadas e escores de dor foram registrados durante todo o período. Medimos a incidência de eventos isquêmicos por indivíduo registrados com monitoração contínua do segmento ST via Holter. Resultados Trinta e um pacientes (IVPCA 14, PL 17) foram incluídos. Não houve eventos cardíacos sérios durante o período de observação. O número de eventos isquêmicos registrados por sujeito durante o período de observação foi de seis no grupo PL e três no grupo IVPCA. Essa diferença não foi estatisticamente significativa (p = 0,618). Não houve diferenças estatisticamente significativas no número de casos com aumento dos valores de troponina no perioperatório (três casos no grupo LP e um caso no grupo IVPCA) ou em termos de escores de dor. Conclusões O uso da analgesia perineural contínua comparado ao da analgesia sistêmica convencional não modifica a incidência de eventos isquêmicos cardíacos no período perioperatório de pacientes idosos com fratura de quadril.

Palavras-chave

Fratura do quadril, Analgesia, Bloqueio do plexo lombar, Complicações cardiovasculares

References

Roche JJW, Wenn RT, Sahota O. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ. 2005;331:1374.

Foss NB. Mortality analysis in hip fracture patients: implications for design of future outcome trials. Br J Anaesth. 2004;94:24-9.

Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth. 2008;55:146-54.

Southwell-Keely JP, Russo RR, March L. Antibiotic prophylaxis in hip fracture surgery: a metaanalysis. Clin Orthop Relat Res. 2004:179-84.

Liu J, Ahn J, Elkassabany NM. Optimizing perioperative care for patients with hip fracture. Anesthesiol Clin. 2014;32:823-39.

Huddleston JM, Gullerud RE, Smither F. Myocardial infarction after hip fracture repair: a population-based study. J Am Geriatr Soc. 2012;60:2020-6.

Scheinin H, Virtanen T, Kentala E. Epidural infusion of bupivacaine and fentanyl reduces perioperative myocardial ischaemia in elderly patients with hip fracture − a randomized controlled trial. Acta Anaesthesiol Scand. 2000;44:1061-70.

Abou-Setta AM, Beaupre LA, Jones CA. Pain management interventions for hip fracture. 2011.

Türker G, Uçkunkaya N, Yavaşçaoğlu B. Comparison of the catheter-technique psoas compartment block and the epidural block for analgesia in partial hip replacement surgery. Acta Anaesthesiol Scand. 2003;47:30-6.

Kheterpal S, O’Reilly M, Englesbe MJ. Preoperative and intraoperative predictors of cardiac adverse events after general, vascular, and urological surgery. Anesthesiology. 2009;110:58-66.

Capdevila X, Macaire P, Dadure C. Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation. Anesth Analg. 2002;94:1606-13.

Landesberg G, Luria MH, Cotev S. Importance of long-duration postoperative ST-segment depression in cardiac morbidity after vascular surgery. Lancet. 1993;341:715-9.

Fleisher LA, Nelson AH, Rosenbaum SH. Postoperative myocardial ischemia: etiology of cardiac morbidity or manifestation of underlying disease?. J Clin Anesth. 1995;7:97-102.

Marsch SC, Schaefer HG, Skarvan K. Perioperative myocardial ischemia in patients undergoing elective hip arthroplasty during lumbar regional anesthesia. Anesthesiology. 1992;76:518-27.

Parker MJ, Griffiths R, Appadu B. Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures. Cochrane Database Syst Rev. 2002:CD001159.

Matot I, Oppenheim-Eden A, Ratrot R. Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia. Anesthesiology. 2003;98:156-63.

Guay J, Parker MJ, Griffiths R. Peripheral nerve blocks for hip fractures. Cochrane Database Syst Rev. 2017;5:CD001159.

Foss NB, Kristensen BB, Bundgaard M. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology. 2007;106:773-8.

Mangano DT, Siliciano D, Hollenberg M. Postoperative myocardial ischemia therapeutic trials using intensive analgesia following surgery. The Study of Perioperative Ischemia (SPI) Research Group. Anesthesiology. 1992;76:342-53.

Rashiq S, Vandermeer B, Abou-Setta AM. Efficacy of supplemental peripheral nerve blockade for hip fracture surgery: multiple treatment comparison. Can J Anesth. 2013;60:230-43.

Roberts HC, Eastwood H. Pain and its control in patients with fractures of the femoral neck while awaiting surgery. Injury. 1994;25:237-9.

Morrison RS, Magaziner J, Gilbert M. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003;58:76-81.

Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4:9-15.

Cuvillon P, Ripart J, Debureaux S. Analgésie postopératoire par cathéter fémoral après fracture du col du fémur chez la personne âgée: étude prospective randomisée. Annales Françaises d’Anesthésie et de Réanimation. 2007;26:2-9.

Abou-Setta AM, Beaupre LA, Rashiq S. Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Ann Intern Med. 2011;155:234-45.

5dcb0edd0e8825d87c03b87a rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections