Lumbo-sacral erector spinae plane and femoral nerve blocks for hip fracture surgery in a critical patient

Dear Editor, Hip surgery in critical patients with femoral fractures poses significant risks due to comorbidities and medications.[1] General anesthesia is challenging for patients with high cardiopulmonary risk, increasing the likelihood of postoperative complications. Regional anesthesia offers advantages in perioperative management[2] and when neuraxial anesthesia is contraindicated due to hemodynamic instability and anticoagulation/aggregation therapies. We report the use of a combination of lumbo-sacral erector spinae plane (L-S ESP) and femoral nerve (FN) blocks as an alternative to conventional approaches for a critical patient who underwent intramedullary nailing after hip fracture. The patient, a 66-year-old male, 160 cm in height and weighing 58 kg (BMI 22.6 kg/m²), was admitted to the Coronary Care Unit with non-ST-elevation myocardial infarction. His medical history included diabetes, heart failure (B-type Natriuretic Peptide > 35,000 pg/mL, 25% ejection fraction), pulmonary hypertension (47 mmHg), peripheral artery disease (Leriche-Fontaine IV with leg amputation), and end-stage renal failure requiring hemodialysis. Laboratory findings revealed pancytopenia (platelet count 85,000). Computed tomography imaging showed a 9 cm pulmonary consolidation, pleural effusion, and ascites. Coronary angiography identified critical three-vessel coronary artery disease, but the patient was deemed unsuitable for cardiac surgery. During hospitalization, the patient experienced an accidental fall, resulting in a femoral fracture. His medications included aspirin, clopidogrel, labetalol, amlodipine, and low molecular weight heparin. He was classified as ASA-PS IV (severe systemic disease/constant threat to life). The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) – Surgical Risk Calculator estimated for this patient a risk of 36.8% of serious complications and death of 47.5%. Given the prohibitive risks associated with neuraxial and general anesthesia, regional anesthesia with intravenous sedation was planned. After obtaining written informed consent, and under monitoring of the vital parameters, we first placed an ultrasound-guided FN block with electro-neurostimulation (0.4 mA), using 7 mL of 0.375% ropivacaine. Then, the patient was positioned in a lateral position on the non-fractured limb for L (3) and S (1) ESP block, administering 20 mL of 0.25% ropivacaine plus 2 mg dexamethasone for each block [Figure 1]. After 30 min, we ascertained a monolateral sensory block of T11 to S2 dermatomes, and the patient was transferred to the operating room. He received intravenously 2 mg of midazolam and 40 mg of ketamine and oxygen via nasal cannula (4 L/min). The surgery lasted 60 min without hemodynamic instability or other complications. No intraoperative opioids were required. Postoperatively, the patient was monitored in the ICU. Pain management included paracetamol 1 g three times daily, with an NRS score <4 in the 48 hours following surgery. No complications were recorded.Figure 1: The sonoanatomy of lumbar and sacral ESP blocks. Panel a shows the relevant sonoanatomy and execution of the lumbar ESP block, with the probe in a sagittal paramedian position, visualizing the transverse processes of L2, L3, and L4. Using a curvilinear probe, the “trident sign” is outlined. The same approach is useful for accessing the lumbar plexus. Panel b shows the ultrasound-guided approach to the sacral ESP block, also using a curvilinear probe, with the needle directed toward the intermediate crest at S1. To be noted the spread of the local anesthetic (LA). TP, transverse process; MF, multifidus muscle (Original figure of the authors)The combination of L-S ESP and FN proved effective for perioperative pain management in this critical patient undergoing hip fracture surgery. The complexity of the nerve supply to the hip joint requires a multi-faceted approach, as a single technique would be insufficient. Hip innervation involves the femoral and obturator (L2–L4), the lateral femoral cutaneous nerves (L2–L3), and posteriorly, the sciatic (L4–S3), the superior gluteal (L4–S1), and the quadratus femoris nerves (L4–S1).[3] Deep blocks, such as lumbar plexus or pericapsular nerve group blocks, were contraindicated due to anticoagulation/antiaggregation. The L-S ESP covered the T11 to S2 dermatomes, while the FN block provided analgesia during positioning.[4,5] To minimize the risks of local anesthetic systemic toxicity, a low-concentration local anesthetic approach was utilized in conjunction with dexamethasone to prolong analgesia. High volumes of anesthetic are crucial for optimal spread in fascial plane blocks. The full effectiveness of the FN block, especially when combined with other blocks, was not completely assessed. Additionally, ESP blocks may have unpredictable dermatomeric coverage and require expertise for effective administration. The patient required conscious sedation (midazolam and ketamine) to enhance surgical conditions and comfort. The L-S ESP block combination, although anecdotal, provided in our case a feasible alternative to neuraxial techniques, avoiding also general anesthesia in an urgent, life-threatening condition. Further research is needed to explore the potential and generalizability of this technique in other cases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.