Monitored Anesthesia Care and Soft Tissue Infiltration with Local Anesthesia: An Anesthetic Option for High-Risk Patients with Hip Fractures.

SUMMARY: This review demonstrates the technique for monitored anesthesia care and soft tissue infiltration with local anesthesia as the only form of anesthesia for short cephalomedullary nailing in medically complex patients. Monitored anesthesia care is defined as providing sedation and analgesia that is titrated to a level that preserves spontaneous breathing and airway reflexes. Soft tissue infiltration refers to soft tissue infiltration with local anesthesia directly into the surgical site and is performed by the surgeon before the start of the procedure.

Monitored Anesthesia Care and Soft-Tissue Infiltration With Local Anesthesia: An Anesthetic Option for High-Risk Patients With Hip Fractures.

OBJECTIVES: To examine the feasibility of a novel anesthetic option for hip fracture fixation with short cephalomedullary nails. DESIGN: Retrospective cohort study. SETTING: The study setting involved an urban, academic Level 1 trauma center, a tertiary care academic medical center, and an orthopaedic specialty hospital. PATIENTS/PARTICIPANTS: Twenty recent and 40 risk-matched (1:1:1 by anesthesia type) historical hip fracture patients were included in the study. INTERVENTION: All patients with an OTA/AO 31.A1-3 intertrochanteric hip fracture presenting from October 1, 2019 to March 31, 2020 treated with a short cephalomedullary nail underwent a new intraoperative anesthesia protocol using monitored anesthesia care (MAC) and soft-tissue infiltration with local anesthesia (STILA). MAIN OUTCOME MEASUREMENTS: Intraoperative measures, postoperative pain scores, narcotic and acetaminophen use, hospital quality measures, and inpatient cost. RESULTS: A total of 60 patients (20 each: MAC, general, and spinal) were identified. There were differences among the groups regarding mean minimum and maximum intraoperative heart rate with MAC-STILA protocol demonstrating the best maintenance of normal heart rate parameters (60-100 beats per minute). For the first 3 hours postoperatively, MAC-STILA patients reported consistently lower pain scores (visual analog scale <1) than spinal or general patients (visual analog scale > 1). Through 48 hours postoperatively, MAC-STILA narcotic usage was similar to that of the spinal cohort and approximately 5 times less than the general cohort. There were no differences in procedural time, length of stay, minor or major complications, inpatient and 30-day mortality, or 30-day readmissions, or postoperative ambulatory distance. There was no difference in inpatient cost among cohorts. CONCLUSIONS: This feasibility study demonstrates safety for the MAC-STILA protocol with comparison to spinal and general anesthesia. The MAC-STILA protocol is a viable option for treatment of OTA/AO 13.A1-3 intertrochanteric fractures with a short cephalomedullary nail and may be the preferred method for patients with severe medical comorbidities or relative contraindications to general and/or spinal anesthesia. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.