Hip/Femur Intertrochanteric Nail

Anesthesia Implications

Position: Supine, one arm extended, operative side arm across chest
Time: 1-2 hours (average)
Blood Loss: High (200 – 500 ml)
Post-op Pain: High (7-10)
Maintenance Paralytic: Yes
Lead: Yes

These patients are typically induced on the bed they come in with. They are then moved to the Hana table. A translucent drape will be put along the lateral side of the patient on the affected/surgical side. The arm on that side will be laid across the chest.

Because of the location of the injury, a tourniquet is not an option. These surgeries can result in significant blood loss.

The patients having this procedure are typically elderly/fragile with multiple comorbidities. Paralytics are typically not necessary. Running the patient low on gases (lower MAC) helps to preserve hemodynamics.

Spinals are difficult to perform as it requires the patient to be in a position that is extremely painful.

High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.

Fluoroscopy / Xray (general considerations): Have lead aprons and thyroid shields available. Alternatively, distancing yourself 3 to 6 feet will reduce scatter radiation to 0.1% to 0.025% respectively. Occupational maximum exposure to radiation should be limited to a maximum average of 20 Sv (joules per kilogram – otherwise known as the Sievert/Sv) per year over a 5 year period. Limits should never exceed 50 Sv in a single year.