A 97-year-old Woman with Comminuted Proximal Femur Fracture Was Successfully Operated under Precise Anesthesia in Shanghai General Hospital in 20 Minutes

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https://www.shobserver.com/staticsg/res/html/web/newsDetail.html?id=530063

The comminuted intertrochanteric fracture of the left femur in a 97-year-old woman is in urgent need of surgical treatment, but the poor cardiopulmonary function and coagulation dysfunction greatly increase the risk of surgical operation. Faced with these problems, the trauma orthopedics team and the anesthesiology team of Shanghai General Hospital successfully performed "closed reduction PFNA internal fixation " for the very elderly patient under precise anesthesia with superb surgical skills. The surgical team completed a series of operations such as reduction, nail implantation and fixation in less than 20 minutes, which maximally protected the patient's poor cardiopulmonary and coagulation function. Under the guidance of the concept of "painless hospital", they implemented refined pain management for the patient after the operation and closely monitored her signs and indicators to help her survive the dangerous period smoothly The patient recovered and discharged on September 16.

In early September, Ms. Huang, 97, was taken to the emergency department of Shanghai General Hospital. After investigation, she was diagnosed with left femoral intertrochanteric comminuted fracture, and Dr. Dehao Fu, director of the Department of Trauma Orthopaedics (North) admitted her to the ward.

Comminuted hip fracture is a great threat to the elderly. If conservative treatment is adopted, the patients have to stay in bed for a long time, and they are prone to complications such as bedsores, pendant pneumonia, urinary system infection, and deep venous thrombosis, and there is a high risk of death; if surgery is performed,  the poor cardiopulmonary function and blood coagulation disorders of the super-elderly are great challenges to the surgical team.

"After the patient was admitted to the ward, we conducted a comprehensive examination and evaluation for her. Her cardiopulmonary system is very poor, and there is a high possibility of myocardial and cerebral infarction during the operation." Dr. Fu told reporters. In order to ensure the safety of the operation, the orthopedic trauma department invited the department of anesthesiology and vascular surgery to conduct further examination and consultation.

With the suggestion of Dr. Jinbao Li, director of the department of anesthesiology, the experts carried out blood coagulation tests such as lung CTA, lower limb arteriovenous ultrasound, lower limb CTV and thromboelastogram for Ms. Huang. The results showed that Ms. Huang's D-dimer index increased seriously (more than 60 times the normal value), and the thromboelastogram test showed that the patient was in a severe hypercoagulable state, which means that the patient may have venous embolism complications such as deep venous thrombosis and pulmonary embolism at any time.

"Theoretically, if elderly patients with intertrochanteric fracture decide to have the surgery, it should be performed as soon as possible. If the patient stays in bed for one more day, the success rate of the operation will drop by one point." Dr. Jinbao Li said, "but this patient's blood coagulation index is too high, anticoagulant therapy must be given firstly, which requires us to balance between preoperative anticoagulant therapy and reducing bed rest time."

After three days of anticoagulant therapy, Ms. Huang's coagulation function and other indicators barely met the standard, and the expert team agreed that the operation should be carried out as soon as possible. However, the risk of general anesthesia for such super-elderly patients is still very high. After careful discussion and assessment, the anesthesia team decided to perform nerve block plus subarachnoid anesthesia for Ms. Huang and perform the operation under "half-body anesthesia".

The advantage of "semi-anaesthesia" surgery is that it has less impact on cardiopulmonary function and blood pressure, and the patients are fully awake, which is also helpful for postoperative recovery, but it also puts forward higher requirements for surgical skills. In order to ensure that the operation was absolutely safe or sure, the orthopaedic trauma team fully discussed, planned and deduced the operation plan before the operation, made an emergency plan for the possible emergency, and prepared the medical equipment that might be needed during the operation.

On the day of the operation, Dr.Jinbao Li guide the team member Dr. Xiebo Zhang and Dr. Qing Yang to block the peripheral nerve of the hip joint for the patient under the guidance of ultrasound. After relieving the pain in the hip of the elderly, a lumbar puncture was performed in the lateral position to accurately control the "anesthesia level" below the 10th thoracic vertebra, reducing the impact on the patient's respiratory and circulatory system, and ensuring the perfusion of important organs. In order to further reduce the tension of patients, the anesthesia team also assisted the use of intravenous sedatives to help patients enter a normal sleeping state.

After the patient was anesthetized, Dr. Dehao Fu cooperated with team members Dr. Yuehua Yang and Dr.Haijiang Ren immediately. Since the duration of half-body anesthesia is shorter than that of general anesthesia, the operation time, which usually requires one to two hours, must be greatly reduced. With rich experience, Dr.Fu quickly completed the traction reduction of the fracture site, and then cut a knife edge of about 5 cm in the left hip, followed by inserting a guide pin, reaming, implanting the proximal femeral nail, and inserting a "spiral blade" for internal fixation. The total process of the operation was successfully completed in less than 20 minutes. The vital signs such as blood pressure and respiration were stable during the operation, and normal dialogue could be carried out after anesthesia resuscitation.

After the surgery, the traumatic orthopedic team closely monitored the patient´s heart failure index and blood index. And the anaesthesia team carried out pain management. Due to the patient's over-age and mild cognitive impairment before operation, the anesthesia team replaced the analgesic pump with a single preoperative nerve block combined with postoperative intravenous analgesia, and the patient's pain score(visual analogue scale, VAS) was always kept below 3 points (mild pain). On the 3rd day after operation, the patient's pain basically disappeared and was discharged from hospital on September 16.

Dr. Jinbao Li said that since 2020, Shanghai General Hospital started the construction of a "painless hospital". The anesthesiology department took the lead in embedding the concept and technology of "pain management" into the whole process of patient care, and set up a hospital-wide standard system for painless diagnosis and treatment. After the patient enters the ward, the anesthesia team in charge of this ward will use the international standard of “pain digital rating scale (NRS)” to evaluate the patient's pain, and then formulate an analgesia program according to the patient's age, degree of trauma, size of operation, etc., and the anaesthesia team will implement pain assessment and continue to evaluate and manage the pain on time.

Correspondent: Yang Hu, Publicity Department at Shanghai General Hospital 

Editor: Shishi Cai, Publicity Department at Shanghai General Hospital