La Rachianesthésie est-elle encore indiquée dans la PTH?

Pr Xavier Capdevila

Département d’Anesthésie et Réanimation, Hôpital Lapeyronie

CHU Montpellier

PLEXUS LOMBAIRE

L1, L2, L3, L4 ± L5 ± T12

Nerf fémoral : L2,L3,L4

Nerf cutané latéral de la cuisse : L2, L3

Nerf obturateur : L2, L3, L4, L5

Nerf ilio-hypogastrique : T12, L1

Nerf ilio-inguinal : L1

Nerf génito-fémoral : L1, L2

PLEXUS SACRE

± L4, L5, S1, S2, S3

Nerf sciatique : L5, S1, S2, S3

Nerf du carré fémoral : L4 ,L5, S1

Nerf glutéal sup : L4, L5, S1

Nerf glutéal inf : L5, S1, S2

Nerf de obt. Interne : L5, S1, S2

Nerf cut. Post. cuisse : S1, S2, S3

Nerf Obturateur

Nerf fémoral Plexus lombaire

Plexus sacré

Face Antérieure

Face Postérieure

T12

CONCLUSIONS: Unilateral SA conducted with bupivacaine hydrochloride and PCSL block technique provided a hemodynamically similar activity in the perioperative period in

patients that underwent partial hip operation

4mg Bupivacaïne

+ 20μg Fentanyl 10mg Bupivacaïne P

Âge (ans) 85 ± 8 82 ± 5 -

Niveau du bloc T8 (T6-T10) T6 (T4-T8) <0.01

PAS la plus basse 0.81 ± 0.10 0.64 ± 0.12 0.001

HypoTA traitées 1/10 9/10 0.001

Total Ephedrine 0.5 ± 1.6 32.0 ± 17.0 <0.001

Besoin en NéoS. 0/10 2/10 -

Patient subgroups: age group “Y” younger than 65 years, “M” 65 to 74 years, “O” 75 years or older

cardiopulmonary disease ‘+’ for yes and ‘−’ for no.

Severe neurological complications in Sweden 1990 -

1999: 127 complications included 33 spinal

hematomas/1 710 000 neuraxial anesthesia

Hematoma Epidural blockade

N= 450 000

Spinal Anesthesia

N= 1.260 000

Man Female Man Female

TKR 1/9000 1/3600 - -

THR - 1/29000 - -

Hip Fract - - - 1/22 000

obstetric 1/200 000 -

Cesarean

Total = 33

1/50 000

1/10 300 1/483 000

Moen Anesthesiology 2004 101,(4) 951-59

*obstetric patients with syndrome of hemolysis,

elevated liver enzymes, and low platelets

• 100,027 total knee and hip replacements under neuraxial anesthesia

• Ninety-seven patients underwent imaging studies to evaluate perioperative neurologic deficits (0.96/1000)

• 8 patients were identified with findings of an epidural blood or gas collec- tion (0.07/1000)

• No patients receiving only spinal anesthesia were affected.

• All patients diagnosed with hematoma took at least 1 drug that potentially impaired coagulation (5 NSAI agents, 1 tricyclic antidepressant, and 1 an antiplatelet drug).

• No patient incurred persistent nerve damage.

In conclusion: The CAM revealed a very low inci- dence rate of postoperative delirium for elderly patients presenting for elective total knee or total hip arthroplasty at Hospital for Special Surgery. The use of regional anesthesia may have also reduced the occurrence of postoperative delirium.

1440 patients suivis

Spinal anesthesia: should everyone receive a urinary catheter?: a randomized, prospective study of patients undergoing total hip arthroplasty.

Miller AG, McKenzie J, Greenky M, Shaw E, Gandhi K, Hozack WJ, Parvizi J.

J Bone Joint Surg Am. 2013, 95:1498-503

• Two hundred patients were included in the study.

• There was no significant difference between the two groups in terms of the prevalence of urinary retention, the prevalence of urinary tract infection, or the length of stay.

• Nine patients in the no-catheter group and three patients in the catheter group (following removal of the catheter) required straight catheterization because of urinary retention.

• CONCLUSIONS: Patients undergoing total hip arthroplasty under spinal anesthesia appear to be at low risk for urinary retention. Thus, a routine indwelling catheter is not required for such patients

173 patients; 170 Spinales

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