The Challenges of Anaesthesia and Pain Relief in Hip Fracture Care

Abstract

The care of the older person with hip fracture is complicated by their comorbid condition, limited physiological reserve, cognitive impairment and frailty. Two aspects of hip fracture management that have received considerable attention are how best to manage the pain associated with it and the ideal mode of anaesthesia. Existing literature has reported on the suboptimal treatment of pain in this orthogeriatric cohort. With recent advancements in medical care, a number of options have emerged as alternatives to conservative systemic analgesia. Systemic analgesia, such as opioids, can lead to untoward side effects, especially in this particular group of patients. Hence, peripheral nerve blocks, epidural analgesia and regional anaesthesia have emerged as options in the delivery of adequate pain relief in hip fractures. Besides that, there is ongoing debate regarding the appropriate anaesthesia technique for surgical repair of the fractured hip. The benefits and risks related to either spinal anaesthesia or general anaesthesia have been subject to studies determining which method is associated with better short- and long-term outcomes. In this review, we aim to examine the evidence behind the different analgesia options available, compare spinal and general anaesthesia, and discuss the importance of the multidisciplinary orthogeriatric model of care in hip fracture and its potential role in other fragility fractures.

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

“…In these studies, quantitative outcome measures of analgesic efficacy (such as pain scores and recorded opiate use), the complications of untreated acute pain (including the incidence of delirium, mortality and other morbidity), and indicators of system efficiency (such as hospital length of stay and adherence to analgesic guidelines) were often only partially explored. Cowan et al's recent literature review supports the suggestion that regional blockade be considered for all those with fractured hips, but acknowledges that pain relief must be individualised and further research is warranted .…”

“…In particular, there is growing recognition of the importance of optimal pain management in the important peri‐operative period. Pain management can be particularly challenging in the physiologically frail and elderly, and the acute trauma setting . This narrative review describes the unique challenges of acute pain management in the elderly, and reviews evidence for the use of regional nerve blockade to provide analgesia after hip fracture in the elderly.…”

Ultrasound-guided popliteal sciatic nerve block: an effective alternative technique to control ischaemic severe rest pain during endovascular treatment of critical limb ischaemia

“…In most cases, pain is intolerably severe, and the control of pain is a critical aspect of the management of these patients [1][2][3]. Although opioids are widely used for the management of pain, they are often associated with dose-dependent, untoward side effects such as nausea and vomiting, sedation, somnolence, or possibly respiratory depression [4][5][6][7]. CLI occurs most frequently among the elderly population, who are most susceptible to the side effects of opioids and the risks of serious physiological complications.…”

“…CLI occurs most frequently among the elderly population, who are most susceptible to the side effects of opioids and the risks of serious physiological complications. The prevalence of co-morbid conditions limited physiological reserve, cognitive impairment, and frailty in patients with CLI sometimes make it difficult to administer opioids to this population [1][2][3][4][5][6][7][8].…”

“…In recent years, there has been growing interest in identifying different analgesic options that are less opioid dependent [3][4][5][6][7]9]. Sciatic nerve block (SNB) is frequently used to induce anaesthesia for lower limb surgery around the knee, ankle, and foot [4][5][6][7][10][11][12][13][14]. It may be used to relieve acute pain emergencies, including distal lower limb fractures, and for postoperative pain control while waiting for alternative medications to become effective.…”