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European Journal of Trauma and Emergency Surgery

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Open Access 07-05-2021 | Opioids | Original Article

The impact of loco-regional anaesthesia on postoperative opioid use in elderly hip fracture patients: an observational study

Authors: Gioia Häusler, Puck C. R. van der Vet, Frank J. P. Beeres, Thomas Kaufman, Jip Q. Kusen, Beate Poblete

Published in: European Journal of Trauma and Emergency Surgery | Issue 4/2022

Abstract

Purpose

Hip fractures are a common health problem among the elderly with an increasing incidence. They are associated with high mortality and morbidity. Optimal pain management remains challenging and inadequate pain control is known for negatively affecting outcomes. Loco-regional anaesthetics (LRA) have been proven to benefit pain management and to lower the risks of opioid use and -related side effects. We aimed to evaluate the use and efficacy of different LRA in elderly hip fracture patients.

Methods

Single-center cohort study of elderly hip fracture patients, who were treated in central Switzerland. We compared patients who received LRA in the form of a femoral nerve block (FNB) or a continuous femoral nerve catheter (CFNC) with patients who did not receive LRA. Primary outcomes were pain—as measured in perioperative morphine use—hospital length of stay (HLOS), postoperative complications, postoperative falls and mortality.

Results

407 patients were included for analysis. Mean age was 85.2 (SD6.3). There was a significant difference in intraoperative morphine use between the groups (p = 0.007). Postoperative morphine use differed significantly and was lowest in patients with FNB and highest in patients without LRA (p < 0.001). The use of LRA was a significant predictor for postoperative morphine use for postoperative morphine use at the recovery room and for postoperative morphine use 48 h after surgery. No significant differences were found in postoperative complications, a significant difference was found in 1-year mortality.

Conclusions

This article shows that LRA in the form of FNB and CFNC causes a significant decrease in postoperative opioid consumption. Differences between single-shot FNB or CFNC were minimal. There were no significant differences in clinical outcomes such as HLOS, delirium, 30-day and 90-day mortality and postoperative falls. We suggest that use of LRA should be incorporated in the perioperative treatment of elderly patients with a hip fracture. For future research, we recommend evaluating the number of postoperative complications and mortality.

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Berry SD, Miller R. Falls: epidemiology, pathophysiology, and relationship to fracture. Curr Osteoporos Rep. 2008;6(4):149–54.CrossRef

Kopp L, Edelmann K, Obruba P, Prochazka B, Blstakova K, Dzupa V. Mortality risk factors in the elderly with proximal femoral fracture treated surgically. Acta Chir Orthop Traumatol Cech. 2009;76(1):41–6.PubMed

Sciard D, Cattano D, Hussain M, Rosenstein A. Perioperative management of proximal hip fractures in the elderly: the surgeon and the anesthesiologist. Minerva Anestesiol. 2011;77(7):715–22.PubMed

Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet (London, England). 2002;359(9319):1761–7. https://doi.org/10.1016/s0140-6736(02)08657-9.CrossRef

Johnell O, Kanis JA. An estimate of the worldwide prevalence, mortality and disability associated with hip fracture. Osteopor Int. 2004;15(11):897–902. https://doi.org/10.1007/s00198-004-1627-0.CrossRef

Roberts HC, Eastwood H. Pain and its control in patients with fractures of the femoral neck while awaiting surgery. Injury. 1994;25(4):237–9.CrossRef

Arsoy D, Gardner MJ, Amanatullah DF, Huddleston JI 3rd, Goodman SB, Maloney WJ, Bishop JA. Continuous femoral nerve catheters decrease opioid-related side effects and increase home disposition rates among geriatric hip fracture patients. J Orthop Trauma. 2017;31(6):e186–9. https://doi.org/10.1097/bot.0000000000000854.CrossRefPubMed

National Clinical Guideline C (2011) National Institute for Health and Clinical Excellence: Guidance. In: The Management of Hip Fracture in Adults. Royal College of Physicians (UK), National Clinical Guideline Centre., London

Chaudet A, Bouhours G, Rineau E, Hamel JF, Leblanc D, Steiger V, Lasocki S. Impact of preoperative continuous femoral blockades on morphine consumption and morphine side effects in hip-fracture patients: a randomized, placebo-controlled study. Anaesthesia, critical care & pain medicine. 2016;35(1):37–43. https://doi.org/10.1016/j.accpm.2015.07.004.CrossRef

10.

Riddell M, Ospina M, Holroyd-Leduc JM. Use of femoral nerve blocks to manage hip fracture pain among older adults in the emergency department: a systematic review. CJEM. 2016;18(4):245–52. https://doi.org/10.1017/cem.2015.94.CrossRefPubMed

11.

Fletcher AK, Rigby AS, Heyes FL. Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med. 2003;41(2):227–33. https://doi.org/10.1067/mem.2003.51.CrossRefPubMed

12.

Haslam L, Lansdown A, Lee J, van der Vyver M. Survey of Current practices: peripheral nerve block utilization by physicians for treatment of pain in the hip fracture patient population. Can Geriatr J. 2013;16(1):16–21. https://doi.org/10.5770/cgj.16.52.CrossRefPubMedPubMedCentral

13.

Lee HK, Kang BS, Kim CS, Choi HJ. Ultrasound-guided regional anesthesia for the pain management of elderly patients with hip fractures in the emergency department. Clin Exp Emerg Med. 2014;1(1):49–55. https://doi.org/10.15441/ceem.14.008.CrossRefPubMedPubMedCentral

14.

Luger TJ, Kammerlander C, Benz M, Luger MF, Garoscio I. Peridural anesthesia or ultrasound-guided continuous 3-in-1 block: which is indicated for analgesia in very elderly patients with hip fracture in the emergency department? Geriatric Orthopaed Surg Rehabil. 2012;3(3):121–8. https://doi.org/10.1177/2151458512470953.CrossRef

15.

Beaudoin FL, Haran JP, Liebmann O. A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Acad Emerg Med Off J Soc Acad Emerg Med. 2013;20(6):584–91. https://doi.org/10.1111/acem.12154.CrossRef

16.

Szucs S, Iohom G, O’Donnell B, Sajgalik P, Ahmad I, Salah N, Shorten G. Analgesic efficacy of continuous femoral nerve block commenced prior to operative fixation of fractured neck of femur. Perioper Med (London, England). 2012;1:4. https://doi.org/10.1186/2047-0525-1-4.CrossRef

17.

von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ (Clin Res Ed). 2007;335(7624):806–8. https://doi.org/10.1136/bmj.39335.541782.AD.CrossRef

18.

Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and dislocation classification compendium-2018. J Orthop Trauma. 2018;32(Suppl 1):S1-s170. https://doi.org/10.1097/bot.0000000000001063.CrossRefPubMed

19.

Owens WD, Felts JA, Spitznagel EL Jr. ASA physical status classifications: a study of consistency of ratings. Anesthesiology. 1978;49(4):239–43. https://doi.org/10.1097/00000542-197810000-00003.CrossRefPubMed

20.

Calculators C (2019) Equianalgesic dosage conversion calculator. https://clincalc.com/Opioids/. Accessed July, 1 2019

21.

WHO (2019) Health topics. World Health Organization. https://www.who.int/topics. Accessed 13, July 2019

22.

Klinik für Anästhesie RuS (2019) Distale Ischiadicusblockade. https://www.sop.klifairs.ch/?page_id=2790. Accessed July, 1, 2019 2019

23.

Helso I, Jantzen C, Lauritzen JB, Jorgensen HL. Opioid usage during admission in hip fracture patients-the effect of the continuous femoral nerve block. Geriatr Orthopaed Surg Rehabil. 2016;7(4):197–201. https://doi.org/10.1177/2151458516672284.CrossRef

24.

Li J, Dai F, Chang D, Harmon E, Ibe I, Sukumar N, Halaszynski TM, Rubin LE, O’Connor MI. A practical analgesia approach to fragility hip fracture: a single-center, retrospective, cohort study on femoral nerve block. J Orthop Trauma. 2019;33(4):175–9. https://doi.org/10.1097/bot.0000000000001391.CrossRefPubMed

25.

Pelt CE, Anderson AW, Anderson MB, Van Dine C, Peters CL. Postoperative falls after total knee arthroplasty in patients with a femoral nerve catheter: can we reduce the incidence? J Arthroplasty. 2014;29(6):1154–7. https://doi.org/10.1016/j.arth.2014.01.006.CrossRefPubMed

26.

Guay J, Kopp S. Peripheral nerve blocks for hip fractures in adults. Cochrane Database Syst Rev. 2020;11:CD001159. https://doi.org/10.1002/14651858.CD001159.pub3.CrossRefPubMed

27.

Polischuk MD, Kattar N, Rajesh A, Gergis T, King K, Sriselvakumar S, Shelfoon C, Lynch G, Campbell K, Cooke C. Emergency department femoral nerve blocks and 1-year mortality in fragility hip fractures. Geriatric orthopaedic surgery & rehabilitation. 2019;10:2151459319893894. https://doi.org/10.1177/2151459319893894.CrossRef

28.

Rowlands M, Walt GV, Bradley J, Mannings A, Armstrong S, Bedforth N, Moppett IK, Sahota O. Femoral Nerve block intervention in neck of femur fracture (FINOF): a randomised controlled trial. BMJ Open. 2018;8(4):e019650. https://doi.org/10.1136/bmjopen-2017-019650.CrossRefPubMedPubMedCentral

29.

Unneby A, Svensson PO, Gustafson PY, Lindgren APB, Bergström U, Olofsson PB. Complications with focus on delirium during hospital stay related to femoral nerve block compared to conventional pain management among patients with hip fracture—a randomised controlled trial. Injury. 2020;51(7):1634–41. https://doi.org/10.1016/j.injury.2020.04.013.CrossRefPubMed

30.

Nie H, Yang YX, Wang Y, Liu Y, Zhao B, Luan B. Effects of continuous fascia iliaca compartment blocks for postoperative analgesia in patients with hip fracture. Pain Res Manag. 2015;20(4):210–2. https://doi.org/10.1155/2015/872651.CrossRefPubMedPubMedCentral

31.

Mouzopoulos G, Vasiliadis G, Lasanianos N, Nikolaras G, Morakis E, Kaminaris M. Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study. J Orthop Traumatol. 2009;10(3):127–33. https://doi.org/10.1007/s10195-009-0062-6.CrossRefPubMedPubMedCentral

32.

Guay J, Parker MJ, Gajendragadkar PR, Kopp S. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev. 2016;2:CD000521. https://doi.org/10.1002/14651858.CD000521.pub3.CrossRefPubMed

33.

Westberg M, Snorrason F, Frihagen F. Preoperative waiting time increased the risk of periprosthetic infection in patients with femoral neck fracture. Acta Orthop. 2013;84(2):124–9. https://doi.org/10.3109/17453674.2013.775044.CrossRefPubMedPubMedCentral

34.

Al-Ani AN, Samuelsson B, Tidermark J, Norling A, Ekström W, Cederholm T, Hedström M. Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am. 2008;90(7):1436–42. https://doi.org/10.2106/jbjs.G.00890.CrossRefPubMed

35.

Pincus D, Ravi B, Wasserstein D, Huang A, Paterson JM, Nathens AB, Kreder HJ, Jenkinson RJ, Wodchis WP. Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. JAMA. 2017;318(20):1994–2003. https://doi.org/10.1001/jama.2017.17606.CrossRefPubMedPubMedCentral

Title: The impact of loco-regional anaesthesia on postoperative opioid use in elderly hip fracture patients: an observational study
Authors: Gioia Häusler
Puck C. R. van der Vet
Frank J. P. Beeres
Thomas Kaufman
Jip Q. Kusen
Beate Poblete
Publication date: 07-05-2021
Publisher: Springer Berlin Heidelberg
Keywords: Opioids
Opioids
Morphine
Nerve Block
Published in: European Journal of Trauma and Emergency Surgery / Issue 4/2022
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-021-01674-4

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

The impact of loco-regional anaesthesia on postoperative opioid use in elderly hip fracture patients: an observational study

Abstract

Purpose

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

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