Anaesthesia 2014, 69, 1172–1182
Correspondence Physiological morbidity associated with hip fracture Fractured neck of femur not only causes considerable mortality [1], but also significant reduction in physiological functioning in the weeks and months after injury. We illustrate this point with the case of a fit, 43-year-old, non-elite cyclist, who suffered a fractured neck of femur after a cycling accident. Cardiopulmonary exercise testing (CPET) data from a previous study (Table 1) were available as a baseline measure, before the injury. The fracture required fixation with a dynamic hip screw performed under general anaesthesia. The subject had an uncomplicated postoperative recovery and was able to weight bear within 24 hours. He restarted exercising on a static bicycle after two weeks, followed by a graded intensive rehabilitation; CPET data were collected again at 8, 12 and 36 weeks, using the Zan 600 cycle ergometer exercise-testing suite (Nspire Health Ltd, Hertford, UK) with anaerobic threshold determined electronically by the V-slope method. Haemoglobin concentration was reduced on the first postoperative
Table 1 Results of cardiopulmonary exercise testing before and after hip fracture. Values are mean (SD) or individual result (number).
V O2 at anaerobic threshold; ml.kg 1.min 1 V O2max; l.min 1
Before injury
After injury 8 weeks
12 weeks
36 weeks
Predicted
32.5 (3.7)
29.4
40.1
36.3
18.4
4.8 (0.1)
3.9
4.9
4.7
2.7
day (100 g.l 1) but had returned to normal (135 g.l 1) by four weeks and remained at this level at 12 weeks. We believe this case will be of interest to readers as it demonstrates a case in which post-injury exercise data can be compared with pre-injury baseline data in traumatic injury. At eight weeks post-injury, the oxygen uptake (V O2) was 25% lower, and the anaerobic threshold (AT) was 10% lower. We think it is unlikely that a decreased haematocrit (and oxygen carrying capacity) contributed to these results, as the haemoglobin concentration had returned to normal at four weeks. By 12 weeks, V O2max had returned to baseline, with an AT above baseline value. Repeat testing at 36 weeks was unchanged. Our subject was highly motivated to regain pre-injury fitness levels, and despite this, return to baseline values still took eight
weeks. Less motivated patients may not be able to attain this level of rehabilitation without help. Rehabilitation programmes have been shown to enhance quality of life and reduce mortality in other diseases [2]. The results from these studies suggest that rehabilitation programmes should specifically target improvements in muscle mass and strength as well as general cardiorespiratory fitness. More work needs to be done to look at this in greater detail, as it may be that rehabilitation programmes need to be tailored far more to individual needs than previously recognised. I. Kerslake Royal United Hospital, Bath, UK Email: [email protected] J. Brown R. Davies Southmead Hospital, Bath, UK
A response to a previously published article or letter must be submitted via the dedicated correspondence website at www.anaesthesiacorrespondence.com, following the guidance there and using the online form (not uploaded as a Word attachment). Please note that a selection of this correspondence will be reproduced (possibly in modified form) in the Journal. Correspondence on new topics should be submitted as an email attachment to [email protected]. Copy should be prepared in the usual style of the Correspondence section. Authors must follow the Guidance for Authors at wileyonlinelibrary.com/journal/anae, including completion and submission of an Author Declaration Form. 1172
© 2014 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
Anaesthesia 2014, 69, 1172–1182
No external funding and no competing interests are declared. JB gave consent for data publication. Previously posted on the Anaesthesia correspondence website: www.anaesthesiacorres pondence.com.
References 1. White SM, Moppett IK, Griffiths R. Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset. Anaesthesia 2014; 69: 224–30. 2. Benington S, McWiliams D, Eddleston J, Atkinson D. Exercise testing in survivors of intensive care – is there a role for cardiopulmonary exercise testing? Journal of Critical Care 2012; 27: 89–94. doi:10.1111/anae.12854
Pecs II or serratus plane block? I read Blanco et al.’s description of the serratus plane block with great interest [1], and have followed its development from their previous descriptions of the pecs I and pecs II blocks [2, 3]. The aim of pecs I was to inject local anaesthetic into the interfascial plane between pectoralis major and minor, blocking the medial and lateral pectoral nerves that innervate both pectoral muscles, which is particularly useful for patients who have breast expanders placed during reconstructive breast cancer surgery or subpectoral prostheses [2]. Pecs II was developed to extend pecs I blockade of the intercostal nerves into the axilla, necessary for axillary clearance, wide excision, tumour removal or mastectomy. This technique consistently blocked the T2-T4 dermatomes, with variable spread to T6, using 10 ml levobupi-
vacaine 0.25% between the pectoral muscles (pecs I) and an additional 20 ml under pectoralis minor above the serratus muscle [3]. In their recent paper [1], however, the local anaesthetic in the pecs II block is shown in the descriptive figures to have been injected underneath the serratus muscle, instead of above it. Did the authors intend this discrepancy and is the relocation based on their increased experience of this block? In their description of the serratus plane block, Blanco et al. demonstrated the area of sensory loss and spread of the injection using magnetic resonance, with longer duration of action and better spread (T2-T9) with superficial vs deep injection to the serratus muscle, but it is uncertain whether the same can be assumed for pecs II block. Are the authors able to offer their opinion as to whether they think this might be the case, and whether serratus plane block should replace pecs II, being easier to perform, safer and associated with better spread? Resolution of these questions will allow true comparisons to be made between these blocks and paravertebral block in providing analgesia after chest wall surgery. M. P. Sebastian University College London Hospital, London, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
© 2014 The Association of Anaesthetists of Great Britain and Ireland
References 1. Blanco R, Parras T, McDonnell JG, PratsGalino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013; 68: 1107–13. 2. Blanco R. The pecs block: a novel technique for providing analgesia after breast surgery. Anaesthesia 2011; 66: 847–8. 3. Blanco R, Fajardo M, Parras T. Ultrasound description of pecs II (modified pecs I): A novel approach to breast sur~ola de Anestesioligery. Revista Espan ogˇ a y Reanimacion 2012; 59: 470–5. doi:10.1111/anae.12822
A reply The aim of the pecs II block is to enter the axillary compartment with the second point of injection. Once the axillary sheath is pierced, the local anaesthetic injected spreads evenly along and across the hemithorax. There is no difference if the point of injection is between serratus anterior and either pectoralis minor or the external intercostal muscle [1]. At the most anterior part of the serratus muscle, it can be more difficult than with pecs I to dissect one plane from the other, in addition, handling of the probe is more complicated at that point. Magnetic resonance imaging with three-dimensional reconstruction found perfect mirror images regarding the point of injection for pecs I and II, suggesting ease of administration and safety were more important factors when developing pecs II. We decided to make the point of injection in contact with the top of the rib under ultrasonography to avoid the needle’s entering the intercostal space. We didn’t investigate the duration of action of pecs II any further, 1173
Correspondence Physiological morbidity associated with hip fracture Fractured neck of femur not only causes considerable mortality [1], but also significant reduction in physiological functioning in the weeks and months after injury. We illustrate this point with the case of a fit, 43-year-old, non-elite cyclist, who suffered a fractured neck of femur after a cycling accident. Cardiopulmonary exercise testing (CPET) data from a previous study (Table 1) were available as a baseline measure, before the injury. The fracture required fixation with a dynamic hip screw performed under general anaesthesia. The subject had an uncomplicated postoperative recovery and was able to weight bear within 24 hours. He restarted exercising on a static bicycle after two weeks, followed by a graded intensive rehabilitation; CPET data were collected again at 8, 12 and 36 weeks, using the Zan 600 cycle ergometer exercise-testing suite (Nspire Health Ltd, Hertford, UK) with anaerobic threshold determined electronically by the V-slope method. Haemoglobin concentration was reduced on the first postoperative
Table 1 Results of cardiopulmonary exercise testing before and after hip fracture. Values are mean (SD) or individual result (number).
V O2 at anaerobic threshold; ml.kg 1.min 1 V O2max; l.min 1
Before injury
After injury 8 weeks
12 weeks
36 weeks
Predicted
32.5 (3.7)
29.4
40.1
36.3
18.4
4.8 (0.1)
3.9
4.9
4.7
2.7
day (100 g.l 1) but had returned to normal (135 g.l 1) by four weeks and remained at this level at 12 weeks. We believe this case will be of interest to readers as it demonstrates a case in which post-injury exercise data can be compared with pre-injury baseline data in traumatic injury. At eight weeks post-injury, the oxygen uptake (V O2) was 25% lower, and the anaerobic threshold (AT) was 10% lower. We think it is unlikely that a decreased haematocrit (and oxygen carrying capacity) contributed to these results, as the haemoglobin concentration had returned to normal at four weeks. By 12 weeks, V O2max had returned to baseline, with an AT above baseline value. Repeat testing at 36 weeks was unchanged. Our subject was highly motivated to regain pre-injury fitness levels, and despite this, return to baseline values still took eight
weeks. Less motivated patients may not be able to attain this level of rehabilitation without help. Rehabilitation programmes have been shown to enhance quality of life and reduce mortality in other diseases [2]. The results from these studies suggest that rehabilitation programmes should specifically target improvements in muscle mass and strength as well as general cardiorespiratory fitness. More work needs to be done to look at this in greater detail, as it may be that rehabilitation programmes need to be tailored far more to individual needs than previously recognised. I. Kerslake Royal United Hospital, Bath, UK Email: [email protected] J. Brown R. Davies Southmead Hospital, Bath, UK
A response to a previously published article or letter must be submitted via the dedicated correspondence website at www.anaesthesiacorrespondence.com, following the guidance there and using the online form (not uploaded as a Word attachment). Please note that a selection of this correspondence will be reproduced (possibly in modified form) in the Journal. Correspondence on new topics should be submitted as an email attachment to [email protected]. Copy should be prepared in the usual style of the Correspondence section. Authors must follow the Guidance for Authors at wileyonlinelibrary.com/journal/anae, including completion and submission of an Author Declaration Form. 1172
© 2014 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
Anaesthesia 2014, 69, 1172–1182
No external funding and no competing interests are declared. JB gave consent for data publication. Previously posted on the Anaesthesia correspondence website: www.anaesthesiacorres pondence.com.
References 1. White SM, Moppett IK, Griffiths R. Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset. Anaesthesia 2014; 69: 224–30. 2. Benington S, McWiliams D, Eddleston J, Atkinson D. Exercise testing in survivors of intensive care – is there a role for cardiopulmonary exercise testing? Journal of Critical Care 2012; 27: 89–94. doi:10.1111/anae.12854
Pecs II or serratus plane block? I read Blanco et al.’s description of the serratus plane block with great interest [1], and have followed its development from their previous descriptions of the pecs I and pecs II blocks [2, 3]. The aim of pecs I was to inject local anaesthetic into the interfascial plane between pectoralis major and minor, blocking the medial and lateral pectoral nerves that innervate both pectoral muscles, which is particularly useful for patients who have breast expanders placed during reconstructive breast cancer surgery or subpectoral prostheses [2]. Pecs II was developed to extend pecs I blockade of the intercostal nerves into the axilla, necessary for axillary clearance, wide excision, tumour removal or mastectomy. This technique consistently blocked the T2-T4 dermatomes, with variable spread to T6, using 10 ml levobupi-
vacaine 0.25% between the pectoral muscles (pecs I) and an additional 20 ml under pectoralis minor above the serratus muscle [3]. In their recent paper [1], however, the local anaesthetic in the pecs II block is shown in the descriptive figures to have been injected underneath the serratus muscle, instead of above it. Did the authors intend this discrepancy and is the relocation based on their increased experience of this block? In their description of the serratus plane block, Blanco et al. demonstrated the area of sensory loss and spread of the injection using magnetic resonance, with longer duration of action and better spread (T2-T9) with superficial vs deep injection to the serratus muscle, but it is uncertain whether the same can be assumed for pecs II block. Are the authors able to offer their opinion as to whether they think this might be the case, and whether serratus plane block should replace pecs II, being easier to perform, safer and associated with better spread? Resolution of these questions will allow true comparisons to be made between these blocks and paravertebral block in providing analgesia after chest wall surgery. M. P. Sebastian University College London Hospital, London, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
© 2014 The Association of Anaesthetists of Great Britain and Ireland
References 1. Blanco R, Parras T, McDonnell JG, PratsGalino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013; 68: 1107–13. 2. Blanco R. The pecs block: a novel technique for providing analgesia after breast surgery. Anaesthesia 2011; 66: 847–8. 3. Blanco R, Fajardo M, Parras T. Ultrasound description of pecs II (modified pecs I): A novel approach to breast sur~ola de Anestesioligery. Revista Espan ogˇ a y Reanimacion 2012; 59: 470–5. doi:10.1111/anae.12822
A reply The aim of the pecs II block is to enter the axillary compartment with the second point of injection. Once the axillary sheath is pierced, the local anaesthetic injected spreads evenly along and across the hemithorax. There is no difference if the point of injection is between serratus anterior and either pectoralis minor or the external intercostal muscle [1]. At the most anterior part of the serratus muscle, it can be more difficult than with pecs I to dissect one plane from the other, in addition, handling of the probe is more complicated at that point. Magnetic resonance imaging with three-dimensional reconstruction found perfect mirror images regarding the point of injection for pecs I and II, suggesting ease of administration and safety were more important factors when developing pecs II. We decided to make the point of injection in contact with the top of the rib under ultrasonography to avoid the needle’s entering the intercostal space. We didn’t investigate the duration of action of pecs II any further, 1173
