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Müller M, Passegger O, Zehnder P, Hanschen M, Muggleton E, Biberthaler P, Wegmann H, Greve F. [Use of regional anesthesia for preoperative analgesia for proximal femoral fractures in the emergency department : A survey on current practice in German-speaking countries and the United Kingdom]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:456-462. [PMID: 37084002 DOI: 10.1007/s00113-023-01315-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Regional anesthesia (RA) techniques such as femoral nerve block (FNB) or fascia iliaca compartment block (FICB) are effective analgesia techniques in the treatment of pain from proximal femoral fractures (PFF). While in Great Britain (GB) these are already frequently used in the emergency department for preoperative analgesia, in the German-speaking D‑A-CH area (Germany, Austria, Switzerland) this seems to occur much less frequently. Therefore, the aim of this study was to survey the type and frequency of RA procedures used and to compare international practice. MATERIAL AND METHODS In the D‑A-CH area as well as in GB, registered emergency departments were contacted and invited to participate in an online survey. The survey included questions on the frequency and type of RA procedures, reasons for non-use, equipment used, person performing the procedure and medications used. RESULTS The participation rate was 17.4% (142/818 emergency departments). RA procedures for preoperative analgesia in PFF were used in 18.3% (21/115) of hospitals in the D‑A-CH region and in 96.3% (26/27) in GB. The most commonly used block was the FICB in GB at 96.2% (25/26) and the FNB in Germany at 66.7% (14/21). In the D‑A-CH area, RA procedures are primarily performed by anesthesiology specialists 71.4% (15/21), and in GB by emergency department residents 65.4% (17/26). DISCUSSION RA procedures are still performed too rarely following PFF in emergency departments in the D‑A-CH area. In international comparison with GB there is potential for improvement.
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Affiliation(s)
- M Müller
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - O Passegger
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - P Zehnder
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - M Hanschen
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - E Muggleton
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik für Anästhesiologie, Technische Universität München, München, Deutschland
- Anästhesie am Josephinum, Klinik Josephinum, München, Deutschland
| | - P Biberthaler
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - H Wegmann
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - F Greve
- Fakultät für Medizin, Klinikum rechts der Isar, Klinik und Poliklinik für Unfallchirurgie, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
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Oura P, Virtanen A, Nurkkala J, Kriikku P, Ojanperä I. Postmortem concentrations of ropivacaine, bupivacaine, and lidocaine in femoral venous blood after hip fracture surgery. Int J Legal Med 2023:10.1007/s00414-023-03000-6. [PMID: 37074413 PMCID: PMC10247554 DOI: 10.1007/s00414-023-03000-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/11/2023] [Indexed: 04/20/2023]
Abstract
Pain relief in hip fracture patients may be sought by injecting local anesthetic such as ropivacaine, bupivacaine, and lidocaine to the femoral area. As femoral veins are a routine sampling site for postmortem blood, this short report aimed to describe the levels of local anesthetics in ipsilateral (i.e., side of surgery) and contralateral (i.e., opposite side) femoral blood in ten medico-legal autopsy cases that had undergone a hip fracture surgery within 7 days before death. Postmortem blood samples were systematically collected from the ipsilateral and contralateral femoral veins, and toxicological analysis was performed in an accredited laboratory. The sample comprised six female and four male decedents who died at the age of 71-96 years. Median postoperative survival was 0 days and median postmortem interval 11 days. Strikingly, ropivacaine concentration was a median of 24.0 (range 1.4-28.4) times higher on the ipsilateral than contralateral side. The median ipsilateral concentration of ropivacaine clearly exceeded the 97.5th reference percentile measured in this laboratory for ropivacaine in postmortem cases representing all causes of death. The remaining drugs did not show high concentrations or notable differences between the sides. Our data clearly advise against performing postmortem toxicology on femoral blood from the operated side; the contralateral side may constitute a better sampling site. Toxicology reports that are based on blood collected from the operated area should be interpreted with caution. Larger studies are needed to confirm the findings, with accurate records of the dosage and administration route of local anesthetics.
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Affiliation(s)
- Petteri Oura
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland.
- Department of Forensic Medicine, Faculty of Medicine, University of Helsinki, P.O. Box 21, 00014, Helsinki, Finland.
| | - Antti Virtanen
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
| | - Juho Nurkkala
- Department of Emergency Medicine and Services, Helsinki University Hospital, P.O. Box 340, 00029, Helsinki, Finland
| | - Pirkko Kriikku
- Department of Forensic Medicine, Faculty of Medicine, University of Helsinki, P.O. Box 21, 00014, Helsinki, Finland
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 3, 00271, Helsinki, Finland
| | - Ilkka Ojanperä
- Department of Forensic Medicine, Faculty of Medicine, University of Helsinki, P.O. Box 21, 00014, Helsinki, Finland
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 3, 00271, Helsinki, Finland
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Effect of Anesthesia Type on Postoperative Outcomes for Hip Fracture Repair: A Systematic Review and Meta-Analysis. AORN J 2023; 117:255-258. [PMID: 36971536 DOI: 10.1002/aorn.13902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 03/29/2023]
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Leibold C, Falbo R, Gupta A, Miller R, Pederson JM, Malpe M. A systematic review and meta-analysis of anesthesia type on hip fracture post-surgery outcomes. OTA Int 2022; 5:e204. [PMID: 36425088 PMCID: PMC9580260 DOI: 10.1097/oi9.0000000000000204] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
Objective To compare technical, clinical, and safety outcomes among hip fracture patients treated with procedures supplemented by general anesthesia (GA) or spinal/regional anesthesia (S/R). Data sources We searched for original studies on PubMed, Ovid MEDLINE, Ovid Embase, and Cochrane databases. Study selection Studies that reported clinical outcomes in patients that underwent hip fracture surgery, had available data on type of anesthesia administered, and clinical follow-up data were selected for data extraction. Data extraction The primary outcomes of interest were odds of mortality, including in-hospital, 30-day, 90-day, and 1-year mortality. Various adverse events (AEs) were also compared. Data synthesis Twenty-eight studies met our selection criteria, including 190,394 patients. A total of 107,314 (56.4%) patients were treated with procedures involving GA while 83,080 (43.6%) were treated with procedures involving S/R. There was no difference in 30-day or >1-year mortality rates between the GA and SR groups; however, compared to S/R group, the GA group had a significantly higher odds of in-hospital (P = .004) and 90-day mortality (P = .004). There was no difference in odds of adverse events between the GA and the S/R group. Conclusions Patients administered S/R for hip fracture procedures demonstrate lower risk of in-hospital mortality and 90-day mortality compared to patients administered GA. Level of evidence Therapeutic level III.
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Affiliation(s)
| | - Ryan Falbo
- Department of Orthopedic Surgery, Mercy Health St. Vincent Medical Center
| | | | - Richard Miller
- Department of Orthopedic Surgery, Mercy Health St. Vincent Medical Center
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Mayel M, Foroughian M, Zamani N, Shahabinejad N, Hassanian‐Moghaddam H. Ultrasound-guided femoral nerve block and intravenous fentanyl in pain management of the patients with hip fracture: a prospective, randomized, single blinded clinical trial. Acute Med Surg 2022; 9:e804. [PMID: 36330310 PMCID: PMC9623599 DOI: 10.1002/ams2.804] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 10/06/2022] [Indexed: 11/23/2022] Open
Abstract
Aim Proximal femoral fracture is a painful condition. Pain alleviation is a treatment cornerstone to both comfort the patient and reduce adverse effects. This study aimed to evaluate and compare ultrasound-guided femoral nerve block and intravenous fentanyl administration in relieving the pain of patients with hip fractures. Methods The present interventional clinical trial was conducted on 40 patients referred to Shahid-Bahonar Hospital with unilateral isolated proximal femur fracture and American Society of Anesthesiologists I and II. The patients were randomly divided into two groups: intravenous fentanyl and ultrasound-guided femoral nerve block for pain management. Pain severity was assessed by a numerical rating scale before and after the intervention in both groups and the groups were then compared. Results Forty patients were enrolled in to study; 27 (67.5%) were male. There was no significant difference in demographic variables between the two groups. Fourteen (35%) were older than 80 years. Pain significantly decreased three scores compared to the pre-intervention level in both groups (95% confidence interval, 2-4). This was slightly higher in the femoral nerve block group. The largest strength of association for age and numerical rating scale of pain was found in the differences between the pre-intervention and after-intervention in femoral nerve block group (r = -0.775, P < 0.001). Conclusion We found similar pain severity between the two groups. Considering the possible side effects of fentanyl, an ultrasound-guided femoral nerve block shows may provide safer pain control and may be particularly suitable for patients with opioid dependence.
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Affiliation(s)
- Masoud Mayel
- Department of Emergency Medicine, School of MedicineKerman University of Medical SciencesKermanIran
| | - Mahdi Foroughian
- Department of Emergency Medicine, School of MedicineKerman University of Medical SciencesKermanIran
| | - Nasim Zamani
- Social Determinants of Health Research CenterShahid Beheshti University of Medical SciencesTehranIran
- Department of Clinical Toxicology, Loghman‐Hakim Hospital, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | | | - Hossein Hassanian‐Moghaddam
- Social Determinants of Health Research CenterShahid Beheshti University of Medical SciencesTehranIran
- Department of Clinical Toxicology, Loghman‐Hakim Hospital, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
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Aftab R, Dixit D, Williams S, Baker L, Raindle Clarke D, Jack C. Cognitive impairment and pain relief following hip fractures: a case control study. Br J Pain 2021; 16:203-213. [PMID: 35419199 PMCID: PMC8998528 DOI: 10.1177/20494637211041146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hip fractures represent a significant workload of both emergency and orthopaedic departments within the National Health Service (NHS). Pain relief is key in treating hip fractures as highlighted by both National Institute of Clinical Excellence (NICE) and British Orthopaedic Association Standards for Trauma (BOAST) guidelines. However, the literature shows that patients with cognitive impairment tend to have inconsistent pain management, leading to worse outcomes. We conducted a case–control study looking at 296 patients who presented with hip fractures to a major trauma centre between 1 December 2019 and 30 May 2020. Cognition was assessed using pre-recorded Abbreviated Mental Test Scores (AMTS). There was no significant difference between pain relief provided to patients with or without cognitive impairment in both the pre-hospital (p = 0.208) and Accident & Emergency (A&E) (p = 0.154) setting. A larger proportion of patients in A&E did not receive any pain relief (18.6% versus 42.2%). Pre-hospital, the higher the pain score, the stronger the analgesia given (R = 0.435, p = 0.000). This relationship was present in both the cognitively impaired (R = 0.572, p = 0.000) and cognitively intact groups (R = 0.390 p = 0.000). Strength of analgesia and pain scores did not correlate in A&E (R = 0.014, p = 0.826). Cognition did not impact the time to analgesia both pre-hospital (p = 0.291) and in A&E (p = 0.332); however, patients waited significantly longer to receive pain relief in A&E (29.61 minutes versus 150.28 minutes). Fascia-iliaca blocks were administered to 58.4% of the cohort, with no significant difference noted between cognition status. Overall, cognition does not impact pain management both pre-hospital and in A&E. There is still room for improvement, particularly in the assessment of pain in the cognitively impaired. A possible solution is the utilisation of the Bolton Pain Assessment Tool, a validated pain assessment tool for the cognitively impaired that has been utilised in the trauma setting with good effect.
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Affiliation(s)
- Raiyyan Aftab
- Department of Trauma and Orthopaedics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Divyansh Dixit
- School of Medicine, University of Southampton, Southampton, UK
| | - Simon Williams
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Laurence Baker
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Christopher Jack
- Department of Trauma and Orthopaedics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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De Vincentis A, Behr AU, Bellelli G, Bravi M, Castaldo A, Galluzzo L, Iolascon G, Maggi S, Martini E, Momoli A, Onder G, Paoletta M, Pietrogrande L, Roselli M, Ruggeri M, Ruggiero C, Santacaterina F, Tritapepe L, Zurlo A, Antonelli Incalzi R. Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus. Aging Clin Exp Res 2021; 33:2405-2443. [PMID: 34287785 DOI: 10.1007/s40520-021-01898-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues. AIM To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF. METHODS A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence. RESULTS A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics). CONCLUSION These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.
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Development and implementation of a perioperative management guide for patients with hip fracture: Health management and clinical impact. ACTA ACUST UNITED AC 2021. [PMID: 34112450 DOI: 10.1016/j.recote.2021.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Hip fracture (HF) in the elderly has a high prevalence and risk of morbidity and mortality in the short and long term. It can reduce life expectancy by almost 2 years, and require permanent socio-sanitary assistance in one in 5 patients. Its management as a process where the patient takes priority over the activities of the organisation can bring new perspectives, optimisation tools and redesign of the workflow to make it more efficient. OBJECTIVE to develop an in-hospital clinical guide for the management of patients with HR adapted to the environment, clear and concise, to be able to intervene in the best possible conditions and favour their adequate recovery. MATERIAL AND METHODS 407 patients divided into 3 groups: pre-implementation (knowing the scope of the problem and areas for improvement); implementation (after the development of the management guide) and post-implementation (valued its implementation). RESULTS The clinical results obtained with this guide allowed improving surgical programming and reducing delay times (increasing the proportion of patients operated in the first 48h and reducing the average hospital stay in 3 days), raising awareness of the problem at all Services involved, improve the management of drugs that altered hemostasia, optimise transfusion therapy and reduce hospital stay and perioperative complications. CONCLUSION The implementation of this guide, with integrated global criteria, has improved the results of this process, and achieved a more efficient management, reducing the consumption of resources and as a consequence, health expenditure.
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Desarrollo e implementación de una guía de manejo perioperatorio de pacientes con fractura de cadera: gestión sanitaria e impacto clínico. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [DOI: 10.1016/j.recot.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Hitka T, O'Sullivan J, Szucs S, Iohom G. Determination of the initial minimum effective dose of 0.5% bupivacaine with 20 μg of fentanyl for an operative fixation of fractured neck of femur: a prospective, observational trial. Minerva Anestesiol 2021; 87:766-773. [PMID: 33591143 DOI: 10.23736/s0375-9393.21.15012-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fractured neck of femur (FNF) is a common cause of morbidity and mortality in elderly. Spinal catheter allows fractionation of local anesthetic dose which combined with intrathecal opioid leads to a dose reduction and better hemodynamic stability. The primary objective of this paper was to investigate the initial minimum local anesthetic dose (iMLAD) of 0.5% isobaric bupivacaine with 20 μg of fentanyl administered via spinal catheter in order to commence the operative fixation of FNF. METHODS A prospective, single-blinded, adaptive clinical trial with patients undergoing dynamic hip screw implantation (DHS) or hemiarthroplasty (HEMI) due to FNF. The Dixon and Massey's up and down method was used to determine the ED50 of intrathecal bupivacaine. This figure was confirmed with Probit analysis, in addition to the ED95. RESULTS Using the Dixon and Massey's approach, the iMLADED50 for DHS was 0.29 mL (1.45 mg) and the iMLADED50 for HEMI was 0.33 mL (1.65 mg) of 0.5% isobaric bupivacaine. The Probit analyses demonstrated that the iMLADED95 for DHS and HEMI were 0.32 mL (1.6 mg) and 0.34 mL (1.7 mg) respectively. The mean cumulative dose of 0.5% bupivacaine for the whole surgery was 0.67 mL (3.35 mg) and 0.87 mL (4.35 mg) in the DHS and HEMI groups, respectively. CONCLUSIONS This study demonstrates that the placement of a spinal catheter allows for careful titration of local anesthetic, enabling a reduction of the initial intrathecal dose of 0.5% isobaric bupivacaine below 0.4 mL (2 mg) and leading to a significant reduction of a dose required for the whole surgery when combined with an intrathecal opioid.
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Affiliation(s)
- Tomas Hitka
- Department of Anesthesia and Intensive Care, Cork University Hospital, Cork, Ireland -
| | - Jane O'Sullivan
- Department of Anesthesia and Intensive Care, Tallaght University Hospital, Dublin, Ireland
| | - Szilard Szucs
- Department of Anesthesia and Intensive Care, Cork University Hospital, Cork, Ireland
| | - Gabriella Iohom
- Cork University Hospital, Cork, Ireland.,University College of Cork, Cork, Ireland
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Alrefaey AK, Abouelela MA. Pericapsular nerve group block for analgesia of positioning pain during spinal anesthesia in hip fracture patients, a randomized controlled study. EGYPTIAN JOURNAL OF ANAESTHESIA 2020. [DOI: 10.1080/11101849.2020.1828017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Alrefaey K. Alrefaey
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed A. Abouelela
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Romanenko A, Кучин Ю, Бєлка К, Токар І. Perioperative pain management in elderly patients with а proximal femoral fracture: evidence review. PAIN MEDICINE 2020. [DOI: 10.31636/pmjua.v4i4.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The purpose of this article is to compare different methods of analgesia during perioperative period in elderly patients with а proximal femoral fracture. The incidence of hip fracture is high and also rises with the age, for example, In Great Britain, number of patients with a hip fracture will be approximately 100 000 in 2033, and it’s also associated with significant healthcare financing. Nevertheless, effective pain management is a big challenge for clinicians because of considerable problems in geriatric patients, including age, physiological changes in the elderly, preexisting comorbidities, cognitive impairment, high risk of delirium, problems with rehabilitation and probability of an independent life [12]. Opioids are still the main option for hip fracture pain management, despite differences in pharmacokinetics and pharmacodynamics in elderly patients, which are correlated with high frequency of side effects. Opioid-related adverse drug events are associated with worse patient outcomes such as morbidity, mortality and length of stay increase. Therefore, peripheral nerve blocks as part of multimodal analgesic technique can provide more effective pain control after hip fracture. Comprehensive literature searches focus on the use of peripheral nerves blocks as preoperative analgesia, as postoperative analgesia or as a supplement to general anesthesia for hip fracture surgery.
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Skjold C, Møller AM, Wildgaard K. Pre-operative femoral nerve block for hip fracture-A systematic review with meta-analysis. Acta Anaesthesiol Scand 2020; 64:23-33. [PMID: 31596943 DOI: 10.1111/aas.13491] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 09/19/2019] [Accepted: 09/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pre-operative pain management of hip fracture patients is complex. Femoral nerve block (FNB) is used for hip fractures to reduce pain and demand for systematic analgesia. The objective of the study was to systematically investigate the efficacy of single-shot FNB for hip fracture patients. METHODS Five databases were searched from inception until 8 May 2019. We included randomized controlled trials (RCT's) assessing pain relief in patients with hip fractures. Intervention was pre-operative FNB compared to any systemic analgesic (eg opioids, non-steroidal anti-inflammatory drugs or paracetamol). Primary outcomes assessed were pre-operative pain and use of rescue analgesics. Secondary outcome was cognitive impairment. We present a bias assessment, a meta-analysis and a grading of certainty of evidence. RESULTS We included five trials (n = 254), where participants received FNB 30 minutes or more prior to surgery; all were judged as having high risk of bias. All studies found significantly decreased pain scores at least once in the intervention group compared to the control group. Meta-analysis on the primary outcome of pain showed significance. Mean difference was -2.13 point (in cm) (CI:-3.53,-0.72) on visual analogue scale in the intervention group, but is judged low on certainty. CONCLUSIONS The quantity of evidence supporting pre-operative single-shot FNB for hip fractures is very low, and the certainty of evidence supporting pre-operative single-shot FNB for hip fractures is low. No studies using ultrasound guided technique were identified. Data on non-ultrasound guided FNB's suggest a decreased pain score compared to the use of systemic analgesia.
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Affiliation(s)
- C. Skjold
- Department of Anaesthesiology Herlev Anaesthesia Critical and Emergency Care Science Unit Herlev Denmark
| | - A. M. Møller
- Department of Anaesthesiology Herlev Anaesthesia Critical and Emergency Care Science Unit Herlev Denmark
| | - K. Wildgaard
- Department of Anaesthesiology Herlev Anaesthesia Critical and Emergency Care Science Unit Herlev Denmark
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Arkley J, Dixon J, Wilson F, Charlton K, Ollivere BJ, Eardley W. Assessment of Nutrition and Supplementation in Patients With Hip Fractures. Geriatr Orthop Surg Rehabil 2019; 10:2151459319879804. [PMID: 31667002 PMCID: PMC6801887 DOI: 10.1177/2151459319879804] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/06/2019] [Indexed: 12/26/2022] Open
Abstract
Introduction: Malnutrition is common in older people, is known to interact with frailty, and is a
risk factor for wound complications and poor functional outcomes postoperatively.
Sustaining a hip fracture is a significant life event, often resulting in a decline in
mobility and functional ability. A poor nutritional state may further impede recovery
and rehabilitation, so strategies to improve perioperative nutrition are of considerable
importance. We provide a review of nutritional supplement practices in this vulnerable
and growing population. Method: Systematic review of preoperative oral nutritional supplementation (ONS) in hip
fracture patients. Results: We identified 12 articles pertaining to this important area of perioperative care. The
findings suggest postoperative ONS can improve postoperative outcomes in hip fracture
patients, especially in terms of increasing total serum protein, improving nutritional
status to near-optimum levels, and decreasing postoperative complications. Discussion: There is an absence of evidence specific to preoperative ONS in patients admitted
following hip fracture. Literature relating to other populations is encouraging but is
yet to be robustly studied. It is unclear whether these results are generalizable to the
frailer hip fracture population. There is a need for studies clearly defining outcome
measurement and complication assessment pertaining to preoperative ONS. The potential
benefit is considerable, and this review will provide a means to inform the construction
of meaningful trials in preoperative ONS of patients sustaining hip fracture. Conclusion: Oral nutritional supplementation in hip fracture patients may decrease postoperative
complications while increasing elderly patient’s nutritional state to a near-optimum
level. This is extrapolated from postoperative literature, however with a clear gap in
research pertaining specifically to preoperative care. The need for well-constructed
studies focused on the impact and assessment of early ONS in this population is
transparent.
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Affiliation(s)
- James Arkley
- Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Ján Dixon
- Newcastle University, Newcastle Upon Tyne, United Kingdom
| | | | - Karl Charlton
- North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | | | - William Eardley
- James Cook University Hospital, Middlesbrough, United Kingdom
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Abstract
PURPOSE OF REVIEW Hip fracture is common in the elderly population, painful and costly. The present investigation was undertaken to review epidemiology, socio-economic and medical implications, relevant anatomy, and anesthetic and pain modalities of hip fracture. RECENT FINDINGS A literature search of PubMed, Ovid Medline, and Cochrane databases was conducted in December 2018 to identify relevant published clinical trials, review articles, and meta-analyses studies related to anesthetic and pain modalities of hip fracture. The acute pain management in these situations is often challenging. Common issues associated with morbidity and mortality include patients' physiological decrease in function, medical comorbidities, and cognitive impairment, which all can confound and complicate pain assessment and treatment. Perioperative multidisciplinary and multimodal approaches require medical, surgical, and anesthesiology teams employing adequate preoperative optimization. Reduction in pain and disability utilizing opioid and non-opioid therapies, regional anesthesia, patient-tailored anesthetic approach, and delirium prevention strategies seems to ensure best outcomes.
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Hsu YP, Hsu CW, Chu KCW, Huang WC, Bai CH, Huang CJ, Cheng SW, Chen JH, Chen C. Efficacy and safety of femoral nerve block for the positioning of femur fracture patients before a spinal block - A systematic review and meta-analysis. PLoS One 2019; 14:e0216337. [PMID: 31048897 PMCID: PMC6497313 DOI: 10.1371/journal.pone.0216337] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 04/18/2019] [Indexed: 12/27/2022] Open
Abstract
Background The evidence supporting the benefit of femoral nerve block (FNB) for positioning before spinal anesthesia (SA) in patients suffering from a femur fracture remains inconclusive. In the present study, the authors intended to determine the efficacy and safety of FNB versus an intravenous analgesic (IVA) for positioning before SA in patients with a femur fracture. Method PubMed, EMBASE, Cochrane, and Scopus databases were searched up to January 2018. We included randomized controlled studies (RCTs) and observational studies that compared FNB versus IVA for the positioning of patients with femur fracture receiving SA. The primary outcome was pain scores during positioning within 30 min before SA. Secondary outcomes were the time for SA, additional analgesic requirements, anesthesiologist’s satisfaction with the quality of positioning for SA, participant acceptance, and hemodynamic changes. A random-effects model was used to synthesize the data. We registered the study at PROSPERO with an ID of CRD42018091450. Results Ten studies with 584 patients were eligible for inclusion. FNB achieved significantly lower pain scores than IVA during positioning within 30 min before SA (pooled standardized mean deviation (SMD): -1.27, 95% confidence interval (CI): -1.84 to -0.70, p < 0.05). A subgroup analysis showed that the analgesic effect was larger in patients in the sitting position for SA than a non-sitting position (sitting position vs non-sitting: pooled SMD: -1.75 (p < 0.05) vs -0.61 (not significant). A multivariate regression showed that the analgesic effect was also associated with age and the total equivalent amount as lidocaine after adjusting for gender (age: coefficient 0.048, p < 0.05; total equivalent amount as lidocaine: coefficient 0.005, p < 0.05). Patients receiving FNB also had a significantly shorter time for SA, greater anesthesiologist satisfaction, and higher patient acceptance than patients receiving IVA. The use of local anesthetics did not produce significant clinical hemodynamic change. Conclusion Compared to IVA, FNB was an effective and safe strategy for the positioning of femur fracture patients for a spinal block, particularly patients who received SA in the sitting position.
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Affiliation(s)
- Yuan-Pin Hsu
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chin-Wang Hsu
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Karen Chia Wen Chu
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wen-Cheng Huang
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chyi-Huey Bai
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chun-Jen Huang
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Sheng-Wei Cheng
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Jin-Hua Chen
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
- Biostatistics Center, College of Management, Taipei Medical University, Taipei, Taiwan
- Department of Medical Education and Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- * E-mail: (CC); (JHC)
| | - Chiehfeng Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Evidence-based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- * E-mail: (CC); (JHC)
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Dixon J, Ashton F, Baker P, Charlton K, Bates C, Eardley W. Assessment and Early Management of Pain in Hip Fractures: The Impact of Paracetamol. Geriatr Orthop Surg Rehabil 2018; 9:2151459318806443. [PMID: 30377550 PMCID: PMC6202735 DOI: 10.1177/2151459318806443] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/06/2018] [Accepted: 09/19/2018] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Ján Dixon
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - Fiona Ashton
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - Paul Baker
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - Karl Charlton
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - Charlotte Bates
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - William Eardley
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
- William Eardley, Department of Trauma & Orthopaedics, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, England, United Kingdom.
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18
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Gulati V, Newman S, Porter KJ, Franco LCS, Wainwright T, Ugoigwe C, Middleton R. Implications of anticoagulant and antiplatelet therapy in patients presenting with hip fractures: a current concepts review. Hip Int 2018; 28:227-233. [PMID: 30165764 DOI: 10.1177/1120700018759300] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The increasing use of anticoagulant and antiplatelet therapy for the prevention of thromboembolic disease poses a significant challenge to orthopaedic surgeons treating elderly patients presenting with proximal femoral fractures. Early surgical intervention is known to be beneficial from a clinical perspective and has been encouraged in the UK through the introduction of best practice tariffs providing increased remuneration for prompt treatment. An understanding of the necessary delay to surgery or reversal options for each type of antiplatelet or anticoagulant agent is therefore important. A number of professional bodies have recently produced guidelines that help clinicians manage these patients during the peri-operative period. We review the guidelines relating to antiplatelet and anticoagulant agents during the perioperative period with respect to hip fracture surgery. Antiplatelet agents should not interfere with timing of surgery, but may affect the choice of anaesthetic performed. The action of warfarin should be reversed to expedite surgery. Newer direct oral anticoagulants are more problematic and surgical delay may be necessary, though reversal agents are becoming available.
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Affiliation(s)
- Vivek Gulati
- 1 Orthopaedic Research Institute, Bournemouth University, Bournemouth UK.,2 Homerton University Hospital, London, UK
| | - Simon Newman
- 1 Orthopaedic Research Institute, Bournemouth University, Bournemouth UK
| | | | | | - Tom Wainwright
- 1 Orthopaedic Research Institute, Bournemouth University, Bournemouth UK
| | | | - Robert Middleton
- 1 Orthopaedic Research Institute, Bournemouth University, Bournemouth UK
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19
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Effect of tranexamic acid use on blood loss and thromboembolic risk in hip fracture surgery: systematic review and meta-analysis. Hip Int 2018; 28:3-10. [PMID: 28983887 DOI: 10.5301/hipint.5000556] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Intravenous tranexamic acid (IV TXA) is a recognised pharmaceutical intervention utilised to minimise blood loss and allogenic blood transfusion. However, the use of IV TXA in hip fracture surgery remains inconclusive. We conducted a meta-analysis to investigate the role of TXA in operative hip fracture management on operative and total blood loss, allogenic blood transfusion requirements and impact on venous thromboembolic (VTE) event incidence. METHODS A systematic computerised literature search of PubMed, Medline, Embase, Ovid, The Cochrane Controlled Trials Register, Trip and Google was conducted. We reviewed the efficacy of IV TXA on perioperative blood loss, total blood loss, pre- and postoperative haemoglobin differences, duration of surgery, allogenic blood transfusion requirements and VTE events. RESULTS 8 studies were eligible including 6 randomised control trials and 2 cohort studies. Patients receiving IV TXA had reduced mean total blood loss of 442.9 mls (95% CI, 426.5-459.3; p<0.00001), reduced operative blood loss of 88.5 mls (95% CI, 59.9-117.2; p<0.00001), a decrease in the need for allogenic blood transfusion (OR 0.37; 95% CI, 0.26-0.53; p<0.00001) and a reduction in pre- and postoperative haemoglobin difference (p = 0.013.) There was no significant increase in VTE risk (OR 1.59; 95% CI 0.67-3.75; p>0.29) or significant difference on duration of surgery seen with IV TXA usage (p>0.06). CONCLUSIONS Our review demonstrated the efficacy of IV TXA in minimising perioperative, reducing total blood loss and lowering the necessity for allogenic blood transfusions with no significant increased risk in VTE events.
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Dawe H. Modernising Hip Fracture Anaesthesia. Open Orthop J 2017; 11:1190-1199. [PMID: 29290856 PMCID: PMC5721325 DOI: 10.2174/1874325001711011190] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 12/14/2022] Open
Abstract
Hip fracture carries a 30-day mortality of around 8% in the United Kingdom. This figure has remained relatively unchanged despite modern developments in anaesthetic technique. These range from improvements in perioperative analgesia and mortality scoring systems, changes to intra-operative anaesthetic technique and strategies to reduce the requirement for blood transfusion. In this article, we review the current literature on the perioperative management of patients undergoing hip fracture surgery including some of the current controversies.
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Affiliation(s)
- Hannah Dawe
- St. Georges Hospital, Tooting, SW170QT, London, UK
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21
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Cowan R, Lim JH, Ong T, Kumar A, Sahota O. The Challenges of Anaesthesia and Pain Relief in Hip Fracture Care. Drugs Aging 2017; 34:1-11. [PMID: 27913981 DOI: 10.1007/s40266-016-0427-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The care of the older person with hip fracture is complicated by their comorbid condition, limited physiological reserve, cognitive impairment and frailty. Two aspects of hip fracture management that have received considerable attention are how best to manage the pain associated with it and the ideal mode of anaesthesia. Existing literature has reported on the suboptimal treatment of pain in this orthogeriatric cohort. With recent advancements in medical care, a number of options have emerged as alternatives to conservative systemic analgesia. Systemic analgesia, such as opioids, can lead to untoward side effects, especially in this particular group of patients. Hence, peripheral nerve blocks, epidural analgesia and regional anaesthesia have emerged as options in the delivery of adequate pain relief in hip fractures. Besides that, there is ongoing debate regarding the appropriate anaesthesia technique for surgical repair of the fractured hip. The benefits and risks related to either spinal anaesthesia or general anaesthesia have been subject to studies determining which method is associated with better short- and long-term outcomes. In this review, we aim to examine the evidence behind the different analgesia options available, compare spinal and general anaesthesia, and discuss the importance of the multidisciplinary orthogeriatric model of care in hip fracture and its potential role in other fragility fractures.
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MESH Headings
- Aged
- Aged, 80 and over
- Analgesia, Epidural/methods
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anesthesia, Conduction/methods
- Anesthesia, General/methods
- Anesthesia, Spinal/methods
- Female
- Hip Fractures/drug therapy
- Hip Fractures/surgery
- Humans
- Male
- Nerve Block/methods
- Pain/prevention & control
- Pain Management/methods
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Affiliation(s)
- Rachel Cowan
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - Jun Hao Lim
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - Terence Ong
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK.
- School of Medicine, University of Nottingham, Medical School, Nottingham, UK.
| | - Ashok Kumar
- School of Medicine, University of Nottingham, Medical School, Nottingham, UK
| | - Opinder Sahota
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
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22
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Hartmann FVG, Novaes MRCG, Carvalho MRD. [Femoral nerve block versus intravenous fentanyl in adult patients with hip fractures - a systematic review]. Rev Bras Anestesiol 2016; 67:67-71. [PMID: 27838114 DOI: 10.1016/j.bjan.2016.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 08/25/2015] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Hip fractures configure an important public health issue and are associated with high mortality taxes and lose of functionality. Hip fractures refer to a fracture occurring between the edge of the femoral head and 5cm below the lesser trochanter. They are common in orthopedic emergencies. The number of proximal femoral fractures is likely to increase as the population ages. The average cost of care during the initial hospitalization for hip fracture can be estimated about US$ 7,000 per patient. Femoral fractures are painful and need immediate adequate analgesia. Treating pain femoral fractures is difficult because there are limited numbers of analgesics available, many of which have side effects that can limit their use. Opiates are the most used drugs, but they can bring some complications. In this context, femoral nerve blocks can be a safe alternative. It is a specific regional anesthetic technique used by doctors in emergency medicine to provide anesthesia and analgesia of the affected leg. OBJECTIVE To compare the analgesic efficacy of intravenous fentanyl versus femoral nerve block before positioning to perform spinal anesthesia in patients with femoral fractures assessed by Pain Scales. METHODS A systematic review of scientific literature was conducted. Studies described as randomized controlled trials comparing femoral nerve block and traditional fentanyl are included. Two reviewers (MR and FH) independently assessed potentially eligible trials for inclusion. The methodology assessment was based on the tool developed by the Cochrane Collaboration for assessment of bias for randomized controlled trials. The Cochrane Library, Pubmed, Medline and Lilacs were searched for all articles published, without restriction of language or time. RESULTS Two studies were included in this review. Nerve blockade seemed to be more effective than intravenous fentanyl for preventing pain in patients suffering from a femoral fracture. It also reduced the use of additional analgesia and made lower the risk for systemic complications. Femoral nerve block reduced the time to perform spinal anesthesia to the patient who will be subjected to surgery and facilitate the sitting position for this. CONCLUSION The use of femoral nerve block can reduce the level of pain and the need for additional analgesia. There are less adverse systemic events associated with this and the procedure itself does not offer greater risks. More studies are required for further conclusions.
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Affiliation(s)
- Flávia Vieira Guimarães Hartmann
- Hospital de Base do Distrito Federal, Brasília, DF, Brasil; Hospital Militar de Área de Brasília, Brasília, DF, Brasil; Fundacão de Ensino e Pesquisa em Ciências da Saúde, Brasília, DF, Brasil; Escola Superior de Ciências da Saúde, Brasília, DF, Brasil.
| | - Maria Rita Carvalho Garbi Novaes
- Farmácia Hospitalar, Departamento de Saúde, Brasília, DF, Brasil; Universidad del Chile, Santiago, Chile; Fundação de Ensino e Pesquisa em Ciências da Saúde, Escola Superior de Ciências da Saúde, Brasília, DF, Brasil
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23
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Hartmann FVG, Novaes MRCG, de Carvalho MR. Femoral nerve block versus intravenous fentanyl in adult patients with hip fractures - a systematic review. Braz J Anesthesiol 2016; 67:67-71. [PMID: 28017173 DOI: 10.1016/j.bjane.2015.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 08/25/2015] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Hip fractures configure an important public health issue and are associated with high mortality taxes and lose of functionality. Hip fractures refer to a fracture occurring between the edge of the femoral head and 5cm below the lesser trochanter. They are common in orthopedic emergencies. The number of proximal femoral fractures is likely to increase as the population ages. The average cost of care during the initial hospitalization for hip fracture can be estimated about US$ 7,000 per patient. Femoral fractures are painful and need immediate adequate analgesia. Treating pain femoral fractures is difficult because there are limited numbers of analgesics available, many of which have side effects that can limit their use. Opiates are the most used drugs, but they can bring some complications. In this context, femoral nerve blocks can be a safe alternative. It is a specific regional anesthetic technique used by doctors in emergency medicine to provide anesthesia and analgesia of the affected leg. OBJECTIVE To compare the analgesic efficacy of intravenous fentanyl versus femoral nerve block before positioning to perform spinal anesthesia in patients with femoral fractures assessed by Pain Scales. METHODS A systematic review of scientific literature was conducted. Studies described as randomized controlled trials comparing femoral nerve block and traditional fentanyl are included. Two reviewers (MR and FH) independently assessed potentially eligible trials for inclusion. The methodology assessment was based on the tool developed by the Cochrane Collaboration for assessment of bias for randomized controlled trials. The Cochrane Library, Pubmed, Medline and Lilacs were searched for all articles published, without restriction of language or time. RESULTS Two studies were included in this review. Nerve blockade seemed to be more effective than intravenous fentanyl for preventing pain in patients suffering from a femoral fracture. It also reduced the use of additional analgesia and made lower the risk for systemic complications. Femoral nerve block reduced the time to perform spinal anesthesia to the patient who will be subjected to surgery and facilitate the sitting position for this. CONCLUSION The use of femoral nerve block can reduce the level of pain and the need for additional analgesia. There are less adverse systemic events associated with this and the procedure itself does not offer greater risks. More studies are required for further conclusions.
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Affiliation(s)
- Flávia Vieira Guimarães Hartmann
- Hospital de Base do Distrito Federal, Brasília, DF, Brazil; Hospital Militar de Área de Brasília, Brasília, DF, Brazil; Fundacão de Ensino e Pesquisa em Ciências da Saúde, Brasília, DF, Brazil; Escola Superior de Ciências da Saúde, Brasília, DF, Brazil.
| | - Maria Rita Carvalho Garbi Novaes
- Farmácia Hospitalar, Departamento de Saúde, Brasília, DF, Brazil; Universidad del Chile, Santiago, Chile; Fundação de Ensino e Pesquisa em Ciências da Saúde, Escola Superior de Ciências da Saúde, Brasília, DF, Brazil
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Carpintero P, Caeiro JR, Carpintero R, Morales A, Silva S, Mesa M. Complications of hip fractures: A review. World J Orthop 2014; 5:402-411. [PMID: 25232517 PMCID: PMC4133447 DOI: 10.5312/wjo.v5.i4.402] [Citation(s) in RCA: 189] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 02/10/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Nowadays, fracture surgery represents a big part of the orthopedic surgeon workload, and usually has associated major clinical and social cost implications. These fractures have several complications. Some of these are medical, and other related to the surgical treatment itself. Medical complications may affect around 20% of patients with hip fracture. Cognitive and neurological alterations, cardiopulmonary affections (alone or combined), venous thromboembolism, gastrointestinal tract bleeding, urinary tract complications, perioperative anemia, electrolytic and metabolic disorders, and pressure scars are the most important medical complications after hip surgery in terms of frequency, increase of length of stay and perioperative mortality. Complications arising from hip fracture surgery are fairly common, and vary depending on whether the fracture is intracapsular or extracapsular. The main problems in intracapsular fractures are biological: vascularization of the femoral head, and lack of periosteum -a major contributor to fracture healing- in the femoral neck. In extracapsular fractures, by contrast, the problem is mechanical, and relates to load-bearing. Early surgical fixation, the role of anti-thromboembolic and anti-infective prophylaxis, good pain control at the perioperative, detection and management of delirium, correct urinary tract management, avoidance of malnutrition, vitamin D supplementation, osteoporosis treatment and advancement of early mobilization to improve functional recovery and falls prevention are basic recommendations for an optimal maintenance of hip fractured patients.
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25
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White S. TAP block--or general anaesthesia? Anaesthesia 2013; 68:867-8. [PMID: 24044445 DOI: 10.1111/anae.12363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- S White
- Royal Sussex County Hospital, Brighton, UK.
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