Regional nerve blockade for early analgesic management of elderly patients with hip fracture – a narrative review

Abstract

Elderly patients with hip fracture experience high morbidity and mortality, and are often undertreated for pain. Acute pain management in the elderly is challenging, with physiological frailty, medical comorbidities and cognitive impairment commonly compounding pain assessment and treatment. Guidelines outlining current best practice for acute pain management in the elderly now exist, but evidence suggests that practice remains variable and there continues to be scope for improvement. We conducted a narrative review of the literature to examine the challenges of acute pain management in the elderly, and to evaluate evidence for the role of regional nerve blocks for acute pain associated with hip fracture in the elderly. There is consistent evidence that regional nerve blocks can effectively reduce pain associated with hip fracture, providing rapid-onset, site-specific analgesia that is more effective than standard systemic analgesia alone. There is also moderate evidence that nerve blocks may contribute to reduced rates of delirium, and some suggestion of reduced length of inpatient stay, morbidity and mortality, although limited evidence is available. Fascia iliaca blocks are emerging as a block of choice, with evidence they can be safely and rapidly administered under ultrasound guidance in the acute setting, by both trained medical and nursing staff, with good effect. Ideally, comprehensive pain protocols for elderly hip fracture patients are required, that integrate evidence-based fascia iliaca block use, timely and repeated pain assessment, and multidisciplinary orthogeriatric patient care.

Pre‐operative femoral nerve block for hip fracture—A systematic review with meta‐analysis

“…The effect of pre‐operative FNB on pain scores and use of rescue medicine has been investigated in other recent reviews, suggesting a decrease in pain scores and the use of rescue analgesics and a reduction in parenteral opiate use . Our review differs in the selection of FNB as we decided to investigate only FNB instead of mixing FNB, 3‐in‐1 femoral nerve block, fascia iliaca compartment block and other variants .…”

“…A narrative review investigating cognitive impairment following nerve block found moderate evidence that nerve blocks may contribute to reduce incidence of delirium, where as a recent systematic review did not find a difference in the incidence of acute confusional state. The narrative review included eight articles with a total of 666 patients, but pooled the results from different nerve blocks as FNB, 3 in 1 femoral nerve block and fascia iliaca block.…”

“…A narrative review investigating cognitive impairment following nerve block found moderate evidence that nerve blocks may contribute to reduce incidence of delirium, where as a recent systematic review did not find a difference in the incidence of acute confusional state. The narrative review included eight articles with a total of 666 patients, but pooled the results from different nerve blocks as FNB, 3 in 1 femoral nerve block and fascia iliaca block. The systematic review included 31 studies with a total of 1760 patients, but pooled the results from several different peripheral nerve blocks, as FNB, 3 in 1 femoral nerve block, fascia iliaca block, psoas block, lateral cutaneous nerve block and obturator block.…”

“…It can be hypothesized that it would have been better to include any type of FNB in the screening process and then screen after method description in order to capture all studies using FNB. Another solution would be to pool all types of block as other, previous reviews have done, followed by a subgroup analyses for the different variants of the blocks.…”

Anesthetic management of geriatric patients

“…In addition, multimodal drug therapy utilizes a variety of nonopioid analgesic medications in order to minimize dosage and prevent adverse effects from opioids while maximizing analgesic benefit [81]. A 2018 review showed that comprehensive pain protocols for elderly hip fracture patients are required, with fascia iliaca blocks as a local anesthesia method of choice [126]. Ultrasound-guided regional anesthesia/analgesia is an important part of anesthesia practice in the elderly population, the growth of which will continue to outpace that of the younger population due to improvements in lifespan worldwide [127].…”