Klimkiewicz Jakub, Klimkiewicz Anna, Gutowski Mateusz, Rustecki Bartosz, Kochanowski Dymitr, Ryczek Robert, Lubas Arkadiusz
Department of Anesthesiology and Intensive Care, Military Institute of Medicine, 04-141 Warsaw, Poland.
Department of Psychiatry, Medical University of Warsaw, 00-665 Warsaw, Poland.
J Clin Med. 2022 Jun 27;11(13):3708. doi: 10.3390/jcm11133708.
Introduction. Intertrochanteric fracture (IF) is a common injury among the elderly. Due to significant comorbidities, anesthesia for IF repair may be challenging. The authors propose femoral nerve block together with a lateral femoral cutaneous nerve block and sedation as an anesthetic technique for most severe cases of IF with contraindications to spinal anesthesia. Methods. In total, 61 patients were enrolled prospectively in a study, 19 received general anesthesia (GA group), 22 spinal anesthesia (SA group), and 20 nerve blocks with sedation (PNB group). Results. Groups were comparable in terms of age, gender, independence, and several comorbidities: diabetes, obesity, underweight, cardiovascular, and cerebrovascular incidents in the past, dementia, chronic obstructive pulmonary disease, and frailty. Heart failure (p = 0.033), hemoglobin < 10 g/dL (p = 0.001) and eGFR < 30 mL/min (p = 0.039) were more frequent in PNB group. PNB group had higher American Society of Anesthesiologists (ASA) (p < 0.001), Nottingham Hip Fracture Score (NHFS) (p < 0.001), and Charlson Comorbidity Index (CCI) (p = 0.002) scales scores, and lower probability of 10-year survival according to CCI (p = 0.012). GA group had more frequent active malignancy (p = 0.041). GA and PNB groups had a higher frequency of hemostasis disorder (p < 0.001). Surgery was completed under the scheduled anesthesia technique. Survival, frequency of cardio and cerebrovascular incidents after surgery, loss of independence, and postoperative delirium were comparable between groups, as well as the length of postoperative stay. Conclusions. Surgical repair of intertrochanteric fracture with intramedullary nailing system among elderly, frail, and sick patients can be conducted under peripheral nerve block. FNB and LFCNB in the combination is a viable option for IT fracture repair.
引言。转子间骨折（IF）是老年人常见的损伤。由于存在严重的合并症，IF修复的麻醉可能具有挑战性。作者提出，对于有脊髓麻醉禁忌证的大多数严重IF病例，股神经阻滞联合股外侧皮神经阻滞及镇静作为一种麻醉技术。方法。总共61例患者前瞻性纳入一项研究，19例接受全身麻醉（GA组），22例接受脊髓麻醉（SA组），20例接受神经阻滞联合镇静（PNB组）。结果。各组在年龄、性别、独立性以及几种合并症方面具有可比性：糖尿病、肥胖、体重过轻、心血管和脑血管疾病史、痴呆、慢性阻塞性肺疾病和虚弱。心力衰竭（p = 0.033）、血红蛋白<10 g/dL（p = 0.001）和估算肾小球滤过率（eGFR）<30 mL/分钟（p = 0.039）在PNB组更为常见。PNB组的美国麻醉医师协会（ASA）（p < 0.001）、诺丁汉髋部骨折评分（NHFS）（p < 0.001）和查尔森合并症指数（CCI）（p = 0.002）量表评分更高，根据CCI计算的10年生存率概率更低（p = 0.012）。GA组有更多的活动性恶性肿瘤（p = 0.041）。GA组和PNB组的止血障碍发生率更高（p < 0.001）。手术在预定的麻醉技术下完成。各组之间的生存率、术后心血管和脑血管事件发生率、独立性丧失、术后谵妄以及术后住院时间相当。结论。对于老年、体弱和患病患者，采用髓内钉系统进行转子间骨折的手术修复可在周围神经阻滞下进行。FNB和LFCNB联合是IF骨折修复的可行选择。
