Time to Block: Early Regional Anesthesia Improves Pain Control in Geriatric Hip Fractures

Abstract

Background: Fascia iliaca nerve blocks (FIBs) anesthetize the thigh and provide opioid-sparing analgesia for geriatric patients with hip fracture awaiting a surgical procedure. FIBs are recommended for preoperative pain management; yet, block administration is often delayed for hours after admission, and delays in pain management lead to worse outcomes. Our objective was to determine whether opioid consumption and pain following a hip fracture are affected by the time to block (TTB). We also examined length of stay and opioid-related adverse events. Methods: This prospective cohort study included patients who were ≥60 years of age, presented with a hip fracture, and received a preoperative FIB from March 2017 to December 2017. Individualized care timelines, including the date and time of admission, block placement, and surgical procedure, were created to evaluate the effect that TTB and time to surgery (TTS) had on outcomes. Patterns among TTB, TTS, and morphine milligram equivalents (MME) were investigated using the Spearman rho correlation. For descriptive purposes, we divided patients into 2 groups based on the median TTB. Multivariable regression for preoperative MME and length of stay was performed to assess the effect of TTB. Results: There were 107 patients, with a mean age of 83.3 years, who received a preoperative FIB. The median TTB was 8.5 hours. Seventy-two percent of preoperative MME consumption occurred before block placement (pre-block MME). A longer TTB was most strongly correlated with pre-block MME (rho = 0.54; p < 0.001), and TTS was not correlated. Patients with a faster TTB consumed fewer opioids preoperatively (12.0 compared with 33.1 MME; p = 0.015), had lower visual analog scale scores for pain on postoperative day 1 (2.8 compared with 3.5 points; p = 0.046), and were discharged earlier (4.0 compared with 5.5 days; p = 0.039). There were no differences in preoperative pain scores, postoperative opioid consumption, delirium, or opioid-related adverse events. Multivariate regression showed that every hour of delay in TTB was associated with a 2.8% increase in preoperative MME and a 1.0% increase in the length of stay. Conclusions: Faster TTB in geriatric patients with hip fracture may reduce opioid use, pain, and length of stay. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fascia Iliaca Blocks Performed in the Emergency Department Decrease Opioid Consumption and Length of Stay in Patients with Hip Fracture

“…First, the prospective recording of patient, nerve block, procedural, and opioid consumption data allowed accurate assessment of the timing and consumption of opioids during different phases of care. Although Garlich et al 24 report that early preoperative FI blocks reduce opioid consumption up to 2 days postoperatively, this study uniquely reports on the continued reduction of opioid consumption throughout the postoperative period and even after the FI block has worn off. To the best of our knowledge, this is also the first study to report a decrease in volume of opioids prescribed at discharge and 30-day readmission rate relating to preoperative FI block.…”

“…22 Williams et al and Garlich et al have previously demonstrated the utility of FI block in reduction of preoperative opioid use when performed in the ED. 23,24 In addition, patients receiving FI block earlier have a greater decrease in opioid consumption. 24 Thompson et al 25 investigated the use of FI block immediately before surgery for postoperative pain control and early ambulation finding a significant decrease in morphine consumption, and nonstatistically significant trend toward increased ambulation.…”

“…23,24 In addition, patients receiving FI block earlier have a greater decrease in opioid consumption. 24 Thompson et al 25 investigated the use of FI block immediately before surgery for postoperative pain control and early ambulation finding a significant decrease in morphine consumption, and nonstatistically significant trend toward increased ambulation. However, there is limited evidence on the efficacy of early FI block performed in the emergency department in decreasing postoperative opioid consumption and in decreasing length of stay.…”

Hip fracture care and mortality among patients treated in dedicated COVID-19 and non-COVID-19 circuits

“…Many of our cases presented with viral pneumonia, fever and hypoxia; guidelines consider chest infections with systemic involvement an acceptable reason for surgical delay [28], and we considered it prudent to avoid the additional inflammatory insult of surgery on patients with systemic involvement. Long-acting regional blocks, repeated if necessary, allow patient mobilisation and facilitate care in addition to reducing opiate demand and avoiding delirium [29,30]. Daily discussion of cases among designated members of all specialties involved (internal medicine or geriatrics, orthopaedic surgeons, anaesthesiologists) is vital to determine the optimum moment of surgery.…”

Postoperative Pain Management

“…A study in patients admitted with hip fractures indicated that a preoperative fascia iliaca nerve block resulted in lower preoperative opioid consumption, lower pain intensities, and earlier discharge. 121 Several factors discourage the use of regional anesthesia, such as lack of clinical experiences or resources and, access to an ultrasound machine which is considered standard-of-care in performing regional anesthesia. Of note, regional anesthesia technique and timing (i.e., when to perform, if a catheter can be placed, when to remove catheter) is also dependent if the patient is on anticoagulation or antiplatelet therapy or has a bleeding disorder.…”