Regional Anesthesia for Short Proximal Femoral Nail (PFN) Insertion
Yes, short Proximal Femoral Nail (PFN) insertion can be safely performed under regional anesthesia, which should be considered the preferred technique unless contraindicated. 1
Benefits of Regional Anesthesia for PFN Insertion
- Regional anesthesia is recommended as the preferred technique for proximal femoral fracture surgeries, including PFN insertion, due to better outcomes in terms of morbidity and mortality 1
- The AAGBI 2011 guidelines specifically recommend regional anesthesia as the preferred technique for proximal femoral fracture repair, based on a meta-analysis of 18,715 patients from 34 randomized controlled trials 1
- Regional anesthesia for PFN insertion leads to reduced intraoperative opioid requirements and potentially better postoperative pain control 2
Types of Regional Anesthesia Suitable for PFN Insertion
- Neuraxial techniques (spinal or epidural anesthesia) are most commonly used for PFN insertion 1
- When using spinal anesthesia, lower doses of local anesthetic and the lateral position are recommended to reduce hemodynamic compromise 1
- The use of fentanyl is preferred over morphine or diamorphine for spinal anesthesia in these procedures 1
Peripheral Nerve Blocks as Adjuncts
- Peripheral nerve blockade should be considered as an adjunct for both pre- and postoperative analgesia in all PFN cases 1
- Peripheral nerve blocks can provide excellent pain control and reduce opioid requirements both before and after surgery 1
- Ultrasound guidance should be used for peripheral nerve blocks to improve accuracy and reduce complications 1
Contraindications to Regional Anesthesia for PFN
- Anticoagulation with INR ≥ 1.5 is a contraindication for neuraxial anesthesia due to risk of spinal hematoma 3
- Platelet count below 50 × 10⁹/L is an absolute contraindication for neuraxial anesthesia 3
- Infection at the injection site is a contraindication for regional anesthesia 3
- Increased intracranial pressure contraindicates neuraxial techniques 3
- Patient refusal or inability to cooperate is a contraindication 3
Technical Considerations
- Thorough testing for block success is essential before proceeding with surgery to minimize the risk of conversion to general anesthesia 1
- Allow extra onset time for peripheral nerve blocks to reduce the risk of intraoperative conversion to general anesthesia 1
- For neuraxial techniques, the patient should be positioned in the lateral position to reduce hemodynamic compromise 1
Multimodal Analgesia Approach
- Regular paracetamol (acetaminophen) should be used as baseline treatment 4
- NSAIDs or COX-2 selective inhibitors should be used unless contraindicated 4
- Opioids should be limited to breakthrough pain as part of a multimodal analgesic regimen 4
- Regular multimodal analgesia should be provided to patients receiving regional techniques to prevent rebound pain after block resolution 4
Considerations for Elderly Patients
- PFN is often used in elderly patients with osteoporotic bone, who benefit from shorter operative times 5
- Regional anesthesia can help reduce operative time and blood loss, which is particularly beneficial in elderly patients with medical comorbidities 5, 6
- Careful hemodynamic monitoring is essential when using regional anesthesia in elderly patients to prevent hypotension 1
Avoiding Complications
- Avoid the combination of general anesthesia and neuraxial block as recommended by AAGBI 2011 1
- Use lower doses of local anesthetic for neuraxial blocks to reduce the risk of hemodynamic compromise 1
- Perform blocks at anatomical sites distant from any active infection to minimize risk of spreading infection 4
- Monitor for compartment syndrome, especially in traumatic cases, though this is less common in proximal femur procedures compared to tibial surgeries 1
Regional anesthesia for short PFN insertion not only provides effective anesthesia but also contributes to better perioperative outcomes with reduced opioid requirements and potentially faster recovery.