Improving pain and function in hip fracture

Icahn School Of Medicine At Mount Sinai, New York NY

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Abstract

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.