Pain Management with Early Regional Anesthesia in Geriatric Hip Fracture Patients

Abstract

BACKGROUND Geriatric hip fracture patients are susceptible to the adverse effects of opioid‐induced analgesia. Fascia iliaca blocks (FIBs) have emerged as an analgesic technique for this population. There are limited data on a preoperative FIB's effect on perioperative opioid intake. We hypothesized that preoperative FIB would reduce perioperative opioid consumption, measured in morphine milliequivalents (MMEs). DESIGN This is a prospective observational study. SETTING A level 1 trauma center in California. PARTICIPANTS From March 2017 to December 2017, patients 65 years and older presenting with a hip fracture received a preoperative FIB and were prospectively observed. This cohort was compared with a historical control. INTERVENTION All prospectively enrolled patients were given FIBs. For a single‐shot FIB, a 30‐ to 40‐mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine was injected. For a continuous FIB, a bolus of 10 to 20 mL of 0.2% bupivacaine was injected, followed by a continuous infusion of 0.2% bupivacaine at 6 mL/h ending on the morning of postoperative Day 1. RESULTS A total of 725 patients were included in this study, with 92 in the prospectively collected cohort. The mean age of this cohort was 84.2 (standard deviation = 8.4) years, and 69.2% were female. Patients who received a preoperative FIB consumed less MME preoperatively, 18.0 (interquartile range = 6.0–44.5) versus 29.5 (interquartile range = 6.0–56.5) (P = .007), with no change in pain scores. No differences were found in postoperative opioid consumption between groups. There was no difference in MME or pain score in patients with dementia. Subgroup analysis based on fracture pattern (femoral neck and intertrochanteric) demonstrated a significant decrease in preoperative MME consumption in femoral neck fractures only, 12.0 (interquartile range = 5.0–24.0) versus 29.0 (interquartile range = 12.0–59.0) (P < .001). CONCLUSION FIBs reduce preoperative opioid intake and have low rates of opioid‐related adverse events in geriatric hip fracture patients. LEVEL OF EVIDENCE The level of evidence was II.

Is Femoral Nerve Block Superior to Fascia Iliac Block in Hip Surgery? Meta-Analysis of Randomized Controlled Trials

“…The low incidence of those side effects can not only effectively improve patient satisfaction but also help patients recover faster after surgery [ 25 ]. Our meta-analysis confirms previous studies reporting decreased postoperative side effects associated with FNB [ 3 , 26 , 27 ].…”

“…A number of complications, such as lower limb deep venous thrombosis and bedsore, can arise as a consequence of postoperative procedures, causing hospitalization and increased medical costs [ 2 ]. It is crucial in clinical practice that the appropriate management is adopted to manage postoperative pain under such circumstances [ 3 ].…”

“…The patient may experience intractable postoperative pain if inappropriate methods of anesthesia were used [ 7 ]. The use of peripheral nerve blocks as a pain management strategy has been recommended following hip surgery due to the adverse effects of opioid analgesics [ 3 ]. Under such circumstances, a femoral nerve block (FNB) and fascia iliac block (FICB) have been proven to result in a lower rate of complications and better pain control in the elderly [ 8 ].…”

Comparison of Femoral Nerve Block and Fascia Iliaca Block for Proximal Femoral Fracture in the Elderly Patient: A Meta-analysis

“… 27 The FNB group showed a reduction in the side effects, which was consistent with the results of previous studies. 3 , 28 , 29 …”

“… 2 Under such circumstances, early provision of analgesia, even before surgical intervention, is a priority. 3 …”