Hip fractures are an important cause of mortality and functional dependence in the United States. Uncontrolled pain is a major impediment to recovery following hip fracture and pain may have a disproportionately greater impact on hip fracture outcomes in geriatric patients than in younger adults. For example, pain can induce tachycardia, increase myocardial oxygen requirements, and produce cardiac ischemia. Untreated pain has been associated with an increased risk of post-operative complications and delirium and has been shown to lead to prolonged bed rest, delayed ambulation, missed or shortened physical therapy sessions, impaired function six months following surgery, and increased hospital costs. Physicians are reluctant to prescribe opioid analgesics to geriatric patients for fear of precipitating side effects (e.g., constipation, delirium, sedation, nausea, respiratory depression) and studies suggest that older adults receive significantly less analgesia than younger adults. Opioid sparing regional anaesthesia techniques represent an attractive intervention in older adults but barriers to undertaking regional techniques immediately upon presentation of patients to the hospital have limited this option to small research studies. Nonetheless, the increasing evidence of pain as an independent risk factor for poorer outcomes in hip fracture heightens the need for effective analgesic strategies for older adults. This project examines the efficacy and effects of 2 regional anesthesia techniques, femoral nerve blocks (FNB) and fascia iliaca blocks (FIB), on the treatment of peri-operative acute hip (femoral neck, intertrochanteric) fracture pain. Patients age 60 years and over presenting to two New York City emergency departments with hip fracture will be randomized to receive the intervention or usual care. The intervention includes single injection FNB in the ED followed by insertion of a continuous FIB catheter within 24 hours of the single injection FNB plus ?as needed? non-opioid/opioid analgesia. Usual care patients will receive conventional therapy with regularly scheduled intravenous or oral opioids plus ?as needed? non/opioids/opioids. We will examine the impact of the intervention on patients'self reported pain intensity;systemic opioid requirements;post-operative function;incidence of delirium, treatment related side effects;and hospital length of stay and participation in physical therapy.
Hip fracture is a devastating disease in older adults resulting in death, disability, and considerable pain. Recent research suggests that pain is not only undertreated in older adults with hip fracture but results in considerable suffering, medical complications, and impaired recovery. This study tests a novel means of providing rapid and effective pain management using regional anesthesia tecniques for hip fracture patients and examines the effect of the intervention of pain and functional recovery. If shown to be effective, the intervention can be easily implemented in hospitals and emergency rooms across the United States.
|Dickman, Eitan; Pushkar, Illya; Likourezos, Antonios et al. (2016) Ultrasound-guided nerve blocks for intracapsular and extracapsular hip fractures. Am J Emerg Med 34:586-9|
|Morrison, R Sean; Dickman, Eitan; Hwang, Ula et al. (2016) Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial. J Am Geriatr Soc 64:2433-2439|
|Akhtar, Saadia; Hwang, Ula; Dickman, Eitan et al. (2013) A brief educational intervention is effective in teaching the femoral nerve block procedure to first-year emergency medicine residents. J Emerg Med 45:726-30|
|Hung, William W; Morrison, R Sean (2011) Hip fracture: a complex illness among complex patients. Ann Intern Med 155:267-8|
|Jeng, Christina L; Torrillo, Toni M; Anderson, Michael R et al. (2011) Development of a mobile ultrasound-guided peripheral nerve block and catheter service. J Ultrasound Med 30:1139-44|
|Reid, M Cary; Bennett, David A; Chen, Wen G et al. (2011) Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them. Pain Med 12:1336-57|
|Darrah, Daniela M; Griebling, Tomas L; Silverstein, Jeffrey H (2009) Postoperative urinary retention. Anesthesiol Clin 27:465-84, table of contents|
|Deiner, S; Silverstein, J H (2009) Postoperative delirium and cognitive dysfunction. Br J Anaesth 103 Suppl 1:i41-46|