Peripheral Nerve Block vs Spinal Anesthesia in Hip Surgery
Condition: Hip Arthroplasty
Study type: Interventional

Summary: 
      Anesthesia plays an important role in the patient's outcome: each anesthesiological technique
      has a different cardiovascular impact, because they act differently on the autonomic nervous
      system, which in turn regulates heart rate, myocardial contractility and vascular tone.

      Subarachnoid anesthesia can result in a reduction in cardiac output, hypotension and
      bradycardia due to blockage of the nerve fibers of the sympathetic system, while peripheral
      nerve block is associated with a lower impact on the autonomic nervous system, therefore less
      influence on hemodynamic changes compared to subarachnoid anesthesia.

      Hypotension can lead to myocardial ischaemia, especially in patients at high surgical risk.

      In addition, peripheral nerve block allows for better coverage from postoperative pain
      compared to subarachnoid anesthesia in patients undergoing hip surgery.

      This leads to less postoperative stress, with less impact on cardiac and respiratory
      function.

      Numerous studies have shown the efficacy and safety of regional anesthesia in hip surgery.

      This study aims to compare the hemodynamic changes of subarachnoid anesthesia and peripheral
      nerve block in patients who underwent total and partial hip replacement
    

Detailed description: 
      All patients who meet the inclusion and exclusion criteria will be enrolled. Enrolled
      patients will be informed of the study modality. In case of a favorable opinion, the patient
      will be made to sign the informed consent. Subsequently a code will be assigned to the
      patient for randomization.

      There are two randomization groups: in the PNB group the patient will undergo lumbar plexus
      block, sciatic nerve block, lateral femoral cutaneous nerve block and lateral branch of
      iliohypogastric nerve block, while in the SA group, the patient will undergo subarachnoid
      anesthesia and lumbar plexus block.

      In the preoperative room, ECG, pulseoximetry will be estabilished and an arterial radial
      cannula will be inserted under local anesthesia to monitor blood pressure. A premedication
      with midazolam (0.05-0.1 mg / kg) will be administered before anesthesia is performed.

      At this point, the type of anesthesia will be followed on the basis of the randomization
      group.

      The following variables will be evaluated:

        -  hemodynamic parameters in the perioperative period

        -  onset time of the sensory and motor block

        -  fluids and vasoactive drugs administered

        -  anesthesiological complications

        -  degree of patient satisfaction

        -  duration of surgery

        -  degree of postoperative pain and analgesic therapy administered

        -  mini mental state evaluation (in the preoperative and postoperative period)

        -  start physical rehabilitation

        -  clinical complications during hospitalization

        -  duration of hospitalization
    

Intervention name(s): Peripheral nerve block; Spinal anesthesia
Intervention type(s): Procedure; Procedure
Intervention description(s): In this group, four nerve blocks will be associated to ensure adequate anesthesia and analgesia during hip surgery.
Lumbar plexus and sciatic nerve blocks will be performed with a needle connected to an electrical nerve stimulation. The needle will be advanced until contraction of the femoral quadriceps muscle and plantar or dorsal flexion of the foot will be detected respectively. For both, a mixture of mepivacaine and levobupivacaine will be injected.
Lateral femoral cutaneous nerve block will be performed with the ultrasound technique. After identifying the nerve, a needle will be inserted with an "in plane" approach and will be injected.
Lateral branch of iliohypogastric nerve block will be executed with the "De Visme approach". Along the iliac crest (range between 7 and 11 cm from the anterior superior iliac spine) a needle will be inserted until bone contact is found. Then a mixture of mepivacaine and levobupivacaine will be injected.; In this group, spinal anesthesia will be performed to ensure anesthesia during surgery, while lumbar plexus block will be performed to ensure postoperative analgesia Spinal anesthesia will be performed with a 25 G needle and 12 mg 0.5% levobupivacaine will be injected.
Lumbar plexus block will be performed with a needle connected to an electrical nerve stimulation. The needle will be advanced until contraction of the femoral quadriceps muscle will be detected. 20 ml 0.5% levobupivacaine will be injected.
Intervention MeSH terms: Anesthetics
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Investigator, Outcomes Assessor)
Primary purpose: Other
Keywords: Regional anesthesia; Hip arthroplasty; Nerve block; Lumbar plexus block