From Grand Rounds from HSS: Management of Complex Cases | Volume 7, Issue 2
An 80-year-old woman with a history of Parkinson’s disease and osteoarthritis, having sustained a left femoral-neck fracture after a fall at her home, was scheduled to undergo open reduction and internal fixation (ORIF). She weighed 55.8 kg (123 lb.), with a body mass index of 18.7. Her medications taken at home included amantadine and carbidopa—levodopa for Parkinson’s disease. The patient had received morphine prior to hospital transfer, and during her preoperative assessment she was oriented to person and place but unable to identify the time of day or year. Her son noted that she had underlying dementia and became easily confused. Given concerns for postoperative delirium related to her age and Parkinson’s, the goal of the anesthesia plan was to minimize postoperative opioid use while providing adequate analgesia.
The patient was taken to the operating room, where she underwent cannulated screw fixation for left hip intracapsular fracture. Spinal anesthesia (1.5% mepivacaine 4 mL) was administered, followed by placement of an epidural catheter for the surgery. She received sedation with fentanyl 100 μg and propofol infusion at 90 μg/kg/min. At the end of the procedure, a suprainguinal fascia iliaca (SIFI) block using 0.25% ropivacaine 30 mL was performed with ultrasound guidance, and a catheter was placed for postoperative analgesia (Fig. 1 and Fig. 2).
Figure 1: Identification of the inguinal ligament using landmarks—the anterior superior iliac spine to the pubis.
Figure 2: (A)The suprainguinal fascia iliaca catheter. (B)Ultrasound image of the suprainguinal fascia iliaca block demonstrating spread of local anesthetic (LA) between the transversus abdominis (TA) and iliacus muscles. Also visualized are the internal oblique (IO) muscle and deep circumflex iliac artery (arrow).
Postoperatively, a solution of 0.2% ropivacaine at 8 mL/hr was infused through the nerve catheter, which provided excellent analgesia. The catheter remained in place with continuous infusion for 43 hours, during which time she did not require opioids. The catheter was removed on postoperative day 2, and she was transitioned to acetaminophen 650 mg (every 6 hours scheduled) and tramadol 50 mg (every 4 hours as needed).
In spite of the avoidance of postoperative opioids, the patient experienced mild confusion starting in the morning on postoperative day 1. The patient’s son noted that she had missed doses of her Parkinson’s medications at home. With resumption of her medication and frequent re-orientation, her cognitive status improved gradually during the hospitalization, with a return to baseline by the time of discharge.
As the population of elderly patients increases, so does the concern for postoperative delirium. It is well established that postoperative delirium is associated with increased hospital length of stay, morbidity, and long-term neurologic sequelae . In particular, hip fractures are common among the elderly, and the use of psychotropic medications including opioids can predispose patients to postoperative delirium . Therefore, strategies that provide effective analgesia while minimizing exposure to such medications are critical. Our case illustrates the use of SIFI block to provide prolonged analgesia and reduce opioid consumption after surgery for hip fracture.
The SIFI block has been demonstrated to provide effective analgesia for hip surgery . The hip joint is innervated by various nerves including branches of the femoral and obturator nerves. The lateral femoral cutaneous nerve (LFCN) innervates the skin of the lateral thigh. The SIFI block involves injection of local anesthetic above the inguinal ligament and between the iliacus and fascia iliaca to anesthetize the femoral and obturator nerves, as well as the LFCN. This technique has been shown to reduce pain and opioid consumption after hip arthroplasty .
A single injection of local anesthetic used for SIFI block may last 24 hours . The catheter provides continuous infusion and prolongs the analgesic effects beyond 24 hours. Our patient underwent ORIF of her femoral neck fracture and did not require postoperative opioids in the first 43 hours while the catheter infusion was used.
Thereafter, she was given scheduled doses of acetaminophen, with tramadol as needed, for analgesia. The use of the SIFI block may provide effective analgesia for hip surgery and potentially minimize opioid use in elderly patients who are at increased risk for postoperative delirium.
Assistant Attending Anesthesiologist, Hospital for Special Surgery
Clinical Instructor of Anesthesiology, Weill Cornell Medical College