Multimodal Analgesia in the Hip Fracture Patient

Abstract

Hip fracture is one of the most common injuries among the elderly and, because the population is aging, it is expected to remain a major clinical challenge and public health problem for the foreseeable future. The clinical importance of early mobilization and prompt participation in physical therapy after hip fracture surgery is now widely recognized. Because postoperative pain can impair mobility and delay physical therapy, much attention is now being paid to finding more effective ways of controlling pain after hip fracture. Oversedation with opioid drugs inhibits communication between the patient and the health care team, can delay ambulation and rehabilitation therapy, and may increase the probability of the patient requiring a skilled nursing facility, which adds further cost to the overall health care system. Multiple pain pathways contribute to the perception of postoperative pain, and although opioids are highly effective in blocking nociceptive pain through inhibition of the mu receptors, they do not block other pain pathways. Multimodal analgesia involves the use of several anesthetic and analgesic modalities that are strategically combined to block pain perception at different sites in the peripheral and central nervous systems. This balanced, multifaceted approach provides more effective control of postoperative pain than opioid drugs alone, allows lower doses of opioids to be used as part of the multimodal regimen (thereby reducing the risk of opioid-related adverse events and complications), and may facilitate more rapid recovery and improve certain outcome measures related to recovery time. One prospective randomized study evaluating the clinical value of multimodal pain management in elderly patients undergoing bipolar hip hemiarthroplasty found that a multimodal regimen, including preemptive pain medication and intraoperative periarticular injections, reduced pain on postoperative days 1 and 4, and reduced overall opioid use. This article describes an effective multimodal pain management regimen for hip fracture patients.

Transmission pathways and mediators as the basis for clinical pharmacology of pain

“…Improved analgesic relief resulted in faster ambulation, more productive physical therapy, and faster overall recovery [194]. Concomitant increases in patient satisfaction were also noted in this study [194]. The multimodal therapy approach is likely to guide pain control in the coming years.…”

“…This approach was also found to have an “opioid-sparing” effect on patients [194]. Improved analgesic relief resulted in faster ambulation, more productive physical therapy, and faster overall recovery [194]. Concomitant increases in patient satisfaction were also noted in this study [194].…”

“…As discussed in a review by Kerfeld et al [193], the use of peripheral and spinal analgesic modalities was effectively able to reduce the need of opioids, decrease the side effects of opioid use, and decrease the length of hospital, all while improving patient satisfaction. In patients with hip fracture undergoing elective repair, Fabi [194] showed that the multimodal analgesic approach provides effective pain relief. This approach was also found to have an “opioid-sparing” effect on patients [194].…”

“…In patients with hip fracture undergoing elective repair, Fabi [194] showed that the multimodal analgesic approach provides effective pain relief. This approach was also found to have an “opioid-sparing” effect on patients [194]. Improved analgesic relief resulted in faster ambulation, more productive physical therapy, and faster overall recovery [194].…”

Hip fracture: A 21st century socio-sanitary epidemic in the first world

“…Manejo adecuado del dolor: El dolor debe abordarse de forma sistemática, multimodal y temprana (38), comenzando en el lugar del accidente por los equipos de emergencias extrahospitalarias y una vez ingresa el paciente en Urgencias pautado por los médicos responsables. No se debe esperar a la confirmación radiológica de la fractura para iniciar el tratamiento analgésico (39).…”