[Analgesia after hip fracture repair in elderly patients: the effect of a continuous femoral nerve block: a prospective and randomised study]

Peripheral Nerve Block and Peri-operative Neurocognitive Disorders in Older Patients With Hip Fractures: A Systematic Review With Meta-analysis

Background

Poor pain control and opioid use are risk factors for perioperative neurocognitive disorders (PND). The peripheral nerve block (PNB) can reduce pain and opioid consumption. This systematic review aimed to investigate the effects of PNB on PND in older patients with hip fractures.

Methods

The PubMed, Cochrane Central Registers of Controlled Trial, Embase and ClinicalTrials.gov databases were searched from inception until November 19, 2021 for all randomized controlled trials (RCTs) comparing PNB with analgesics. The quality of the selected studies was assessed according to Version 2 of the Cochrane tool for assessing the risk of bias in RCTs. The primary outcome was the incidence of PND. Secondary outcomes included pain intensity and the incidence of postoperative nausea and vomiting. Subgroup analyses were based on population characteristics, type and infusion method of local anesthetics, and type of PNB.

Results

Eight RCTs comprising 1015 older patients with hip fractures were included. Compared with analgesics, PNB did not reduce the incidence of PND in the elderly hip fracture population comprising patients with intact cognition and those with pre-existing dementia or cognitive impairment (risk ratio [RR] = .67; 95% confidence interval [CI] = .42 to 1.08; P = .10; I2 = 64%). However, PNB reduced the incidence of PND in older patients with intact cognition (RR = .61; 95% CI = .41 to .91; P = .02; I2 = 0%). Fascia iliaca compartment block, bupivacaine, and continuous infusion of local anesthetics were found to reduce the incidence of PND.

Conclusions

PNB effectively reduced PND in older patients with hip fractures and intact cognition. When the study population included patients with intact cognition and those with pre-existing dementia or cognitive impairment, PNB showed no reduction in the incidence of PND. These conclusions should be confirmed with larger, higher-quality RCTs.

Hip Fracture Surgery: Regional Anesthesia and Opioid Demand

BACKGROUND

Hip fracture surgery is painful, and regional anesthesia (RA) has been used in an attempt to reduce pain and opioid consumption after surgery. Despite potential analgesic benefits, the effect of RA on inpatient and outpatient opioid demand is not well known. We hypothesized that RA would be associated with decreased inpatient opioid demand and has little effect on outpatient opioid demand in hip fracture surgery.

METHODS

This study retrospectively evaluated all patients of 18 years and older undergoing hip fracture surgery from July 2013 to July 2018 at a single, level I trauma center (n = 1,659). Inpatient opioid consumption in 24-hour increments up to 72-hour postoperative and outpatient opioid prescribing up to 90-day postoperative were recorded in oxycodone 5-mg equivalents (OE's). Adjusted models evaluated the effect of RA on opioid demand after adjusting for other baseline and treatment variables.

RESULTS

After adjusting for baseline and treatment variables, there were small increases in inpatient opioid consumption in patients with RA (2.6 estimated OE's without RA versus three OE's with RA from 0 to 24 hours postoperatively, 2.1 versus 2.4 from 24 to 48 hours postoperatively, and 1.6 versus 2.2 from 48 to 72 hours postoperatively, all P values for RA <0.001). However, there were no notable differences in outpatient opioid demand.

DISCUSSION

RA did not decrease inpatient or outpatient opioid demand in patients undergoing hip fracture surgery in this pragmatic study. In fact, there were slight increases in inpatient opioid consumption, although these differences are likely clinically insignificant. These results temper enthusiasm for RA in hip fracture surgery.

LEVEL OF EVIDENCE

Level III, retrospective, therapeutic cohort study.

The effect of regional nerve block on perioperative delirium in hip fracture surgery for the elderly: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

With minimal systemic toxicity, an analgesic effect of regional nerve block (RNB) has been proved in hip fracture cases. Analgesia was expected to reduce delirium by controlling pain, a known predisposing factor for delirium. We performed a meta-analysis to investigate the effect of RNB on delirium after hip fracture surgery in elderly patients. We aimed to answer the question: Can regional nerve block reduce postoperative delirium in hip fracture patients?

HYPOTHESIS

Our hypothesis was that RNB could reduce postoperative delirium after hip fracture surgery in elderly patients.

PATIENTS AND METHODS

MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before September 9, 2020, investigating the effect of RNB on perioperative delirium after hip fracture in elderly patients. We performed synthetic analyses for overall RNB compared to a control group both in 1) overall elderly patients, including the cognitively impaired, and 2) for patients without cognitive impairment (CoI). Also, we performed subgroup analyses for each of the block techniques, such as fascia-iliac block (FIB) and femoral nerve block (FNB).

RESULTS

Eight randomized controlled trials compared the incidence of perioperative delirium between the RNB and control groups. A pooled analysis showed no differences in delirium incidence between the RNB and control groups (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.36-1.22; p=0.18; I²=58%) in overall elderly patients. However, there was a significant reduction of delirium in the RNB group in patients without CoI (OR: 0.44; 95% CI: 0.21-0.94; p=0.03; I²=51%). In the subgroup analyses, we were unable to discern any differences in delirium incidence between the groups for FIB (OR, 0.89; 95% CI: 0.19-4.19; p=0.88; I²=78%) and FNB (OR 0.61; 95% CI: 0.31-1.20, p=0.15, I²=47%).

CONCLUSIONS

In cases of hip fracture in elderly, RNB demonstrated a preventive effect on perioperative delirium for patients without preoperative CoI. No significant reduction in perioperative delirium was observed when cognitively impaired patients were included.

Peripheral nerve blocks for hip fractures in adults

BACKGROUND

This review was published originally in 1999 and was updated in 2001, 2002, 2009, 2017, and 2020. Updating was deemed necessary due to the high incidence of hip fractures, the large number of official societies providing recommendations on this condition, the possibility that perioperative peripheral nerve blocks (PNBs) may improve patient outcomes, and the major role that PNBs may play in reducing preoperative and postoperative opioid use for analgesia.

OBJECTIVES

To compare PNBs used as preoperative analgesia, as postoperative analgesia, or as a supplement to general anaesthesia versus no nerve block (or sham block) for adults with hip fracture. Outcomes were pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction, chest infection, death, time to first mobilization, and costs of an analgesic regimen for single-injection blocks. We undertook the update to look for new studies and to update the methods to reflect Cochrane standards.

SEARCH METHODS

For the updated review, we searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 11), in the Cochrane Library; MEDLINE (Ovid SP, 1966 to November 2019); Embase (Ovid SP, 1974 to November 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to November 2019), as well as trial registers and reference lists of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing use of PNBs compared with no nerve block (or sham block) as part of the care provided for adults 16 years of age and older with hip fracture.  DATA COLLECTION AND ANALYSIS: Two review authors independently screened new trials for inclusion, assessed trial quality using the Cochrane Risk of Bias-2 tool, and extracted data. When appropriate, we pooled results of outcome measures. We rated the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 49 trials (3061 participants; 1553 randomized to PNBs and 1508 to no nerve block (or sham block)). For this update, we added 18 new trials. Trials were published from 1981 to 2020. Trialists followed participants for periods ranging from 5 minutes to 12 months. The average age of participants ranged from 59 to 89 years. People with dementia were often excluded from the included trials. Additional analgesia was available for all participants. Results of 11 trials with 503 participants show that PNBs reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.05, 95% confidence interval (CI) -1.25 to -0.86; equivalent to -2.5 on a scale from 0 to 10; high-certainty evidence). Effect size was proportionate to the concentration of local anaesthetic used (P = 0.0003). Based on 13 trials with 1072 participants, PNBs reduce the risk of acute confusional state (risk ratio (RR) 0.67, 95% CI 0.50 to 0.90; number needed to treat for an additional beneficial outcome (NNTB) 12, 95% CI 7 to 47; high-certainty evidence). For myocardial infarction, there were no events in one trial with 31 participants (RR not estimable; low-certainty evidence). From three trials with 131 participants, PNBs probably reduce the risk for chest infection (RR 0.41, 95% CI 0.19 to 0.89; NNTB 7, 95% CI 5 to 72; moderate-certainty evidence). Based on 11 trials with 617 participants, the effects of PNBs on mortality within six months are uncertain due to very serious imprecision (RR 0.87, 95% CI 0.47 to 1.60; low-certainty evidence). From three trials with 208 participants, PNBs likely reduce time to first mobilization (mean difference (MD) -10.80 hours, 95% CI -12.83 to -8.77 hours; moderate-certainty evidence). One trial with 75 participants indicated there may be a small reduction in the cost of analgesic drugs with a single-injection PNB (MD -4.40 euros, 95% CI -4.84 to -3.96 euros; low-certainty evidence). We identified 29 ongoing trials, of which 15 were first posted or at least were last updated after 1 January 2018.  AUTHORS' CONCLUSIONS: PNBs reduce pain on movement within 30 minutes after block placement, risk of acute confusional state, and probably also reduce the risk of chest infection and time to first mobilization. There may be a small reduction in the cost of analgesic drugs for single-injection PNB. We did not find a difference for myocardial infarction and mortality, but the numbers of participants included for these two outcomes were insufficient. Although randomized clinical trials may not be the best way to establish risks associated with an intervention, our review confirms low risks of permanent injury associated with PNBs, as found by others. Some trials are ongoing, but it is unclear whether any further RCTs should be registered, given the benefits found. Good-quality non-randomized trials with appropriate sample size may help to clarify the potential effects of PNBs on myocardial infarction and mortality.

Assessment and Early Management of Pain in Hip Fractures: The Impact of Paracetamol

Introduction

As the number of patients sustaining hip fractures increases, interventions aimed at improving patient comfort and reducing complication burden acquire increased importance. Frailty, cognitive impairment, and difficulty in assessing pain control characterize this population. In order to inform future care, a review of pain assessment and the use of preoperative intravenous paracetamol (IVP) is presented.

Materials and Methods

Systematic review of preoperative IVP administration in patients presenting with a hip fracture.

Results

Intravenous paracetamol is effective in the early management of pain control in the hip fracture population. There is a considerable decrease in use of breakthrough pain medications when compared with other pain relief modalities. Additionally, IVP reduces the incidence of opioid-induced complications, reduces length of stay, and lowers mean pain scores. Another significant finding of this study is the poor administration of all analgesics to patients with hip fracture with up to 72% receiving no prehospital analgesia.

Discussion

The potential benefits of IVP as routine in the early management of hip fracture-related pain are clear. Studies of direct comparison between analgesia regimes to inform optimum bundles of analgesic care are sparse. This study highlights the need for properly constructed pathway-driven comparator studies of contemporary analgesia regimes, with IVP as a central feature to optimize pain control and minimize analgesia-related morbidity in this vulnerable population.

[Perioperative lumbar plexus block and cardiac ischemia in patients with hip fracture: randomized clinical trial]

BACKGROUND

Perioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject.

METHODS

Patients older than 60 years, ASA II-III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient-controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST-segment Holter monitoring.

RESULTS

Thirty-one patients (intravenous patient-controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient-controlled analgesia group. This difference was not statistically significant (p=0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient-controlled analgesia group) or in terms of pain scores.

CONCLUSIONS

Using continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Femoral Nerve Block Intervention in Neck of Femur Fracture (FINOF): a randomised controlled trial

OBJECTIVE

Fractured neck of femur is a severely painful condition with significant mortality and morbidity. We investigated whether early and continuous use of femoral nerve block can improve pain on movement and mobility after surgery in older participants with fragility neck of femur fracture.

DESIGN

Prospective single-centre, randomised controlled pragmatic trial.

SETTING

Secondary care, acute National Health Service Trust, UK.

PARTICIPANTS

Participants admitted with a history and examination suggesting fractured neck of femur.

INTERVENTION

Immediate continuous femoral nerve block via catheter or standard analgesia.

OUTCOME MEASURES

Primary outcome measures were Cumulative Dynamic Pain score and Cumulated Ambulation Score from surgery until day 3 postoperatively. Secondary outcome measures included pain scores at rest, cumulative side effects (nausea and constipation), quality of life (measured by EuroQOL 5 D instrument (EQ-5D) score) at day 3 and day 30, and rehabilitation outcome (measured by mobility score).

RESULTS

141 participants were recruited, with 23 excluded. No significant difference was detected between Cumulative Dynamic Pain Score (standard care (n=56) vs intervention (n=55) 20 (IQR 15-24) vs 20 (15-23), p=0.51) or Cumulated Ambulation Score (standard care vs intervention 6 (5-9) vs 7 (5-10), p=0.76). There were no statistically different differences in secondary outcomes except cumulative pain at rest: 5 (0.5-6.5) in the standard care group and 2 (0-5) in the intervention group (p=0.043).

CONCLUSIONS

Early application of continuous femoral nerve block compared with standard systemic analgesia did not result in improved dynamic pain score or superior postoperative ambulation. This technique may provide superior pain relief at rest. Continuous femoral nerve block did not delay initial control of pain or mobilisation after surgery.

TRIAL REGISTRATION NUMBER

ISRCTN92946117; Pre-results.

Peripheral nerve blocks for hip fractures

BACKGROUND

Various nerve blocks with local anaesthetic agents have been used to reduce pain after hip fracture and subsequent surgery. This review was published originally in 1999 and was updated in 2001, 2002, 2009 and 2017.

OBJECTIVES

This review focuses on the use of peripheral nerves blocks as preoperative analgesia, as postoperative analgesia or as a supplement to general anaesthesia for hip fracture surgery. We undertook the update to look for new studies and to update the methods to reflect Cochrane standards.

SEARCH METHODS

For the updated review, we searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8), MEDLINE (Ovid SP, 1966 to August week 1 2016), Embase (Ovid SP, 1988 to 2016 August week 1) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to August week 1 2016), as well as trial registers and reference lists of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) involving use of nerve blocks as part of the care provided for adults aged 16 years and older with hip fracture.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed new trials for inclusion, determined trial quality using the Cochrane tool and extracted data. When appropriate, we pooled results of outcome measures. We rated the quality of evidence according to the GRADE Working Group approach.

MAIN RESULTS

We included 31 trials (1760 participants; 897 randomized to peripheral nerve blocks and 863 to no regional blockade). Results of eight trials with 373 participants show that peripheral nerve blocks reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.41, 95% confidence interval (CI) -2.14 to -0.67; equivalent to -3.4 on a scale from 0 to 10; I² = 90%; high quality of evidence). Effect size was proportionate to the concentration of local anaesthetic used (P < 0.00001). Based on seven trials with 676 participants, we did not find a difference in the risk of acute confusional state (risk ratio (RR) 0.69, 95% CI 0.38 to 1.27; I² = 48%; very low quality of evidence). Three trials with 131 participants reported decreased risk for pneumonia (RR 0.41, 95% CI 0.19 to 0.89; I² = 3%; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 5 to 72; moderate quality of evidence). We did not find a difference in risk of myocardial ischaemia or death within six months, but the number of participants included was well below the optimal information size for these two outcomes. Two trials with 155 participants reported that peripheral nerve blocks also reduced time to first mobilization after surgery (mean difference -11.25 hours, 95% CI -14.34 to -8.15 hours; I² = 52%; moderate quality of evidence). One trial with 75 participants indicated that the cost of analgesic drugs was lower when they were given as a single shot block (SMD -3.48, 95% CI -4.23 to -2.74; moderate quality of evidence).

AUTHORS' CONCLUSIONS

High-quality evidence shows that regional blockade reduces pain on movement within 30 minutes after block placement. Moderate-quality evidence shows reduced risk for pneumonia, decreased time to first mobilization and cost reduction of the analgesic regimen (single shot blocks).

Opioid Usage During Admission in Hip Fracture Patients-The Effect of the Continuous Femoral Nerve Block

INTRODUCTION

The aim of this study was to investigate whether there was a difference in opioid usage during admission for hip fracture patients with continuous femoral nerve block (cFNB) when compared to patients nonfemoral nerve block (nFNB).

METHODS AND MATERIALS

Patients were identified from the local database on all hip fracture patients admitted to Bispebjerg University Hospital, Denmark. Four hundred fifty-six hip fracture patients were included during the period September 2008 to October 2010.

RESULTS

Three hundred sixty-six hip fracture patients had cFNB. The mean time with cFNB was 3.4 days. There were no significant differences in gender, length of stay, time to surgery, mortality rate, in-hospital falls, or resurgery rates during admission between the 2 groups. The nFNB group had an insignificant higher use of morphine as needed during the first 5 days of admission (nFNB: 53.1 mg, 95% confidence interval [CI]: 34.4-71.7; cFNB: 47.7 mg, 95% CI: 40.7-64.3; P = .54) and during the whole admission (cFNB: 34.3 mg, 95% CI: 23.2-45.5; cFNB: 30.3 mg, 95% CI: 26.6-33.0; P = .4). Some 8.47% of the total morphine consumption during admission was morphine as needed for the nFNB group and 9.89% for the cFNB group.

CONCLUSION

Patients with cFNB did only have a marginally lower opioid usage during admission when compared to patients without the block, with no significance between the 2 groups. This could indicate that the cFNB is an ineffective analgesic strategy, especially in the postoperative period, but larger randomized studies are needed in order to clarify this.

Local Anaesthetic Infiltration and Indwelling Postoperative Wound Catheters for Patients with Hip Fracture Reduce Death Rates and Length of Stay

Background. An analgesic enhanced recovery (ER) protocol for patients with a hip fracture was introduced. It was hypothesised that the ER would reduce pain, length of stay and improve clinical outcomes. The protocol used intraoperative infiltration of levobupivacaine followed by ongoing wound infusions. Methods. Consecutive patients admitted to two hospitals were eligible for the ER protocol. Numerical Reporting Scale pain scores (0–10) were recorded alongside opiate requirements. 434 patients in the ER group (316 full ER, 90 partial ER, and 28 no ER) were compared to a control group (CG) of 100 consecutive patients managed with traditional opiate analgesia. Results. Mean opiate requirement was 49.2 mg (CG) versus 32.5 mg (ER). Pain scores were significantly reduced in the full ER group, p < 0.0001. Direct discharge home and mean acute inpatient stay were significantly reduced (p = 0.0031 and p < 0.0001, resp.). 30-day mortality was 15% (CG) versus 5.5% (ER), p = 0.0024. Conclusions. This analgesic ER protocol for patients with a hip fracture was safe and effective and was associated with reduced inpatient stay and mortality.

Impact of preoperative continuous femoral blockades on morphine consumption and morphine side effects in hip-fracture patients: A randomized, placebo-controlled study

BACKGROUND

Upon arrival at the emergency department, hip-fracture pain relief is usually carried out via systemic opioids. Continuous nerve blocks are efficient in the postoperative period, but have not been evaluated preoperatively. This study compared the reduction in morphine consumption and related side effects of a continuous femoral block with a single shot block in hip-fracture patients.

METHODS

Hip-fracture patients admitted to the emergency department received a femoral nerve catheter, with a single lidocaine injection. They were then randomized to ropivacaine (group R) or saline continuous infusion (placebo, group P) in a double-blind manner. Morphine consumption and side effects were prospectively collected until the 24th postoperative hour.

RESULTS

Sixty patients were included and 55 analyzed. There were no significant differences between the 2 groups regarding fracture types, delay before surgery (median [Q1-Q3]: 21.3 [14.5-29.4] versus 20.8 [15.7-36.2] hours for groups R and P, respectively; P=0.87) and catheter duration (47.5 [39.8-52.4] versus 42.5 [32.1-50.5] hours, P=0.29). Total morphine consumption was not significantly decreased in group R (5 [0-14] versus 8 [4.5-11] mg, P=0.3) and pain scores were similar (mean±SD; VAS 29±15/100 versus 33±13, P=0.3). We observed a significant reduction in morphine adverse effects (31% versus 69% for groups R and P, respectively; P<0.01), mainly nausea (31% versus 59%, P=0.03). One morphine side effect could be avoided for every 5 patients treated.

CONCLUSION

Preoperative continuous femoral blockades using ropivacaine reduce morphine side effects (mainly nausea) in hip-fracture patients without reducing morphine consumption.

Femoral nerve block Intervention in Neck of Femur fracture (FINOF): study protocol for a randomized controlled trial

BACKGROUND

Hip fractures are very painful leading to lengthy hospital stays. Conventional methods of treating pain are limited. Non-steroidal anti-inflammatories are relatively contraindicated and opioids have significant side effects.Regional anaesthesia holds promise but results from these techniques are inconsistent. Trials to date have been inconclusive with regard to which blocks to use and for how long. Interpatient variability remains a problem.

METHODS/DESIGN

This is a single centre study conducted at Queen's Medical Centre, Nottingham; a large regional trauma centre in England. It is a pragmatic, parallel arm, randomized controlled trial. Sample size will be 150 participants (75 in each group). Randomization will be web-based, using computer generated concealed tables (service provided by Nottingham University Clinical Trials Unit). There is no blinding. Intervention will be a femoral nerve block (0.5 mls/kg 0.25% levo-bupivacaine) followed by ropivacaine (0.2% 5 ml/hr-1) infused via a femoral nerve catheter until 48 hours post-surgery. The control group will receive standard care. Participants will be aged over 70 years, cognitively intact (abbreviated mental score of seven or more), able to provide informed consent, and admitted directly through the Emergency Department from their place of residence. Primary outcomes will be cumulative ambulation score (from day 1 to 3 postoperatively) and cumulative dynamic pain scores (day 1 to 3 postoperatively). Secondary outcomes will be cumulative dynamic pain score preoperatively, cumulative side effects, cumulative calorific and protein intake, EUROQOL EQ-5D score, length of stay, and rehabilitation outcome (measured by mobility score).

DISCUSSION

Many studies have shown the effectiveness of regional blockade in neck of femur fractures, but the techniques used have varied. This study aims to identify whether early and continuous femoral nerve block can be effective in relieving pain and enhancing mobilization.Trial registration.

TRIAL REGISTRATION

The trial is registered with the European clinical trials database Eudract ref: 2010-023871-25. (17/02/2011).

ISRCTN

ISRCTN92946117. Registered 26 October 2012.

Improving hip fracture care: striving for excellence

Hip fracture is a common and potentially devastating injury that occurs mainly in older people. The incidence is predicted to rise by 30% in the next 10 years alone. Many of those who recover suffer a loss of mobility and independence. There is growing emphasis to improve the care of patients sustaining hip fracture, especially in those with concurrent cognitive impairment. This review focuses on current best practice as well as several key areas of management, including analgesia, anaemia and nutrition. In doing so, we hope to identify interventions that may form the basis of a future Enhanced Recovery Pathway dedicated to hip fracture care.

Efficacy of supplemental peripheral nerve blockade for hip fracture surgery: multiple treatment comparison

PURPOSE

This study was designed to determine the most effective peripheral nerve block supplement to standard anesthesia management for hip fracture patients.

METHODS

We systematically reviewed randomized controlled trials (RCTs) published from 1990 to 2010 and conducted multiple treatment comparisons using direct and indirect evidence for two outcomes, i.e., acute pain intensity and delirium. We combined trials by type of injection (regardless of time of insertion during the perioperative phase, use of nerve block catheter, local anesthetic type, additives, or duration of treatment).

RESULTS

Twenty-one RCTs comprising 1,422 participants were included. In most cases, the trials were conducted in Europe; they excluded patients with cognitive impairment, and they were unclear or at high risk of bias. The combination of obturator and lateral femoral cutaneous nerve blockade had the highest probability of being the most effective against acute postoperative pain. Fascia iliaca blockade had the highest probability of being the most effective against delirium. There was no difference in outcomes among other nerve blocks.

CONCLUSION

Not all nerve blocks are equally effective in improving outcomes after hip fracture. Multiple treatment comparison, a tool to compare the effectiveness of multiple treatments simultaneously, provides useful guidance to anesthesia providers seeking effective treatment when faced with a body of RCTs wherein each investigates one treatment. More RCTs comparing multiple nerve blocks in hip fracture are needed.

Management of postoperative pain: experience of the Niamey National Hospital, Niger

OBJECTIVE

The aim of this study was to evaluate the management of postoperative pain at the Niamey National Hospital.

METHODS

A prospective study was conducted in the Department of Anesthesiology and Intensive Care at the Niamey National Hospital from March to June, 2009. Data collected included age, sex, literacy, American Society of Anesthesiologists (ASA) physical status classification, type of anesthesia, type of surgery, postoperative analgesics used, and the cost of analgesics. Three types of pain assessment scale were used depending on the patient's ability to describe his or her pain: the verbal rating scale (VRS), the numerical rating scale (NRS), or the visual analog scale (VAS). Patients were evaluated during the first 48 hours following surgery.

RESULTS

The sample included 553 patients. The VRS was used for the evaluation of 72% of patients, the NRS for 14.4%, and the VAS for 13.6%. Of the VRS group, 33.9%, 8.3%, and 2.1% rated their pain as 3 or 4 out of 4 at 12, 24, and 48 hours postoperatively, respectively. For the NRS group, 33.8%, 8.8%, and 2.5% rated their pain as greater than 7 out of 10 at 12, 24, and 48 hours postoperatively, respectively. For the VAS group, 29.3%, 5.4%, and 0% rated their pain as greater than 7 out of 10 at 12, 24, and 48 hours postoperatively, respectively.

CONCLUSION

Postoperative pain assessment and management in developing countries has not been well described. Poverty, illiteracy, and inadequate training of physicians and other health personnel contribute to the underutilization of postoperative analgesia. Analysis of the results gathered at the Niamey National Hospital gives baseline data that can be the impetus to increase training in pain management and to establish standardized protocols.

Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland

There should be protocol-driven, fast-track admission of patients with hip fractures through the emergency department. Patients with hip fractures require multidisciplinary care, led by orthogeriatricians. Surgery is the best analgesic for hip fractures. Surgical repair of hip fractures should occur within 48 hours of hospital admission. Surgery and anaesthesia must be undertaken by appropriately experienced surgeons and anaesthetists. There must be high-quality communication between clinicians and allied health professionals. Early mobilisation is a key part of the management of patients with hip fractures. Pre-operative management should include consideration of planning for discharge from hospital. Measures should be taken to prevent secondary falls. 10. Continuous audit and targeted research is required in order to inform and improve the management of patients with hip fracture.

[Influence of the fascia iliaca compartment block on postoperative cognitive status in the elderly]

OBJECTIVE

The aim of this study was to assess the influence of a regional analgesia technique on the incidence of postoperative cognitive dysfunction (POCD) after hip surgery, in elderly patients.

PATIENTS AND METHODS

Patients, aged over 65 years, were assigned in two groups according to the anaesthesia technique: group NKT (general anaesthesia with target concentration infusion of propofol and remifentanil, with a 0.1 mg/kg-bolus of morphine at the end of surgery), group KT (preoperative iliaca compartment block with catheter and then general anaesthesia without bolus of morphine). Postoperative analgesia was similar in both groups: paracetamol, tramadol, and subcutaneous morphine if verbal pain scale equal or greater than 2 (0.1 mg/kg). POCD was defined as a decrease in Mini Mental Status (MMSE) equal or greater than 2 points and was monitored during 2 days. Consumption of opioids, pain scores and side effects were recorded.

RESULTS

Sixty-five patients were included: 34 in NKT group and 31 in KT group. MMSE scores were higher in the KT group at day 1 and day 2 (p=0.01 and 0.0004, respectively). POCD was less frequent in group KT at day 2 (6 % vs 41 % ; p=0.001) and pain scores were lower during the first 48 hours (p=0.03). Remifentanil consumption was lower in KT group (0.43+/-0.18 mg vs 0.61+/-0.25 mg, p=0.002). Total amount of morphine, including the bolus in NKT group, was significantly lower in KT group (7 [5-17] mg vs 0 [0-5] mg, p<10(-6)).

CONCLUSION

Postoperative analgesia by iliaca compartment block with catheter seems to provide a decrease in the incidence of POCD after hip surgery in elderly patients.

STUDY DESIGN

Prospective, observational study.

Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures

BACKGROUND

Various nerve blocks using local anaesthetic agents have been used in order to reduce pain after hip fracture.

OBJECTIVES

To determine the effects of nerve blocks (inserted either pre-operatively, operatively or post-operatively) as part of the treatment for a hip fracture.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (October 2001), MEDLINE -OVID WEB (1996 to October 2001) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials involving the use of nerve blocks as part of the care of a hip fracture patient.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality, by use of a nine item scale, and extracted data. Wherever appropriate, results of outcome measures were pooled.

MAIN RESULTS

Eight randomised or quasi-randomised trials involving 328 patients were included. Three trials related to insertion of a nerve block pre-operatively and the remaining five to peri-operative insertion. Nerve blocks resulted in a reduction of the quantity of parenteral or oral analgesia administered to control pain from the fracture/operation or during surgery and/or a reduction in reported pain levels. It was not possible to demonstrate if this reduction in analgesia use was associated with any other clinical benefit.

REVIEWER'S CONCLUSIONS

Because of the small number of patients included in this review and the differing type of nerve blocks and timing of insertion, it is not possible to determine if nerve blocks confer any significant benefit when compared with other analgesic methods as part of the treatment of a hip fracture. Further trials with larger numbers of patients and full reporting of clinical outcomes would be justified.