Emerging evidence suggests that patients who suffer hip fractures and other traumatic injuries are at risk of prolonged opioid use when inadequate analgesia occurs. For anesthesiologists, proper acute pain management is imperative, from preoperative patient assessment to the postoperative recovery stage. Uncontrolled pain can be detrimental, and if the analgesic needs of patients with trauma are forgotten, a high risk of long-term opioid use is posed.
Recent studies have shown a proven benefit of regional anesthesia and multimodal analgesia in patients with orthopedic trauma, and evidence has mounted for the use of peripheral nerve blocks in reducing opioid use, reducing pain, lowering mortality rates, and preserving motor function in patients with hip fractures.
Jinlei Li, MD, PhD, Associate Professor and Director of Regional Anesthesia at Yale New Haven Hospital, urged that missing or dismissing analgesic needs of patients with orthopedic trauma could result in respiratory failure, intubation, ICU admission, and a slowdown of physical therapy and rehabilitation. Use of regional anesthesia could make the difference in patient outcomes, she said. “Regional anesthesia plays a significant role in hip fracture, not only by lowering pain and decreasing opioid consumption, but it is also associated with lower solid organ complication rates, less respiratory failure, earlier physical therapy, and faster recovery without an increase in the risk of falling,” she said.
Peripheral nerve blocks promising regional anesthesia benefits
Studies have shown that peripheral nerve blocks are typically well-tolerated and provide superior regional analgesia compared to alternatives such as systematic pain medications. “Peripheral nerve blocks should be offered unless contraindicated, and overwhelming evidence supports its use for hip fractures in perioperative pain control, which is universally accepted by the anesthesia and surgical communities,” Dr. Li said.
Despite a high certainty of benefit and wider acceptance of use, McGinn et al. found variation in peripheral nerve block utilization for hip fracture, leading to suboptimal patient outcomes (Br J Anaesth 2022;128:198-206). Of the 50,950 patients included in the study, only 18.5% received a peripheral nerve block within one day of surgery. It was found that patient-level factors accounted for only 14% of use variation, while over 40% was attributable to either the anesthesiologist or the institution providing care. Interventions to increase the uptake of peripheral nerve block for patients with hip fracture would need to focus on hospital- and anesthesiologist-level processes, the study noted.
Dr. Li said that interdisciplinary care programs that utilize peripheral nerve blocks as regional anesthesia play an important role. “It starts from preoperative nerve blocks and moves to perioperative opioid-sparing multimodal analgesia – and post-discharge care should be well-planned as well,” she shared.
Guay and Kopp found that when comparing peripheral nerve blocks used as preoperative analgesia, as postoperative analgesia, or as a supplement to general anesthesia versus no nerve block for adults with hip fracture, peripheral nerve blocks reduced pain on movement within 30 minutes of placement by 2.5 on a scale of 1 to 10 (Cochrane Database Syst Rev 2020 Nov 25;11:CD001159). In addition, use of peripheral nerve blocks reduced the risk of confusion and chest infections and shortened the time to first mobilization after surgery by 11 hours.
Research by D-Yin Lin et al. found that nerve blocks performed in both the emergency department and OR were associated with reduced long-term mortality (Reg Anesth Pain Med 2023;48:14-21). Researchers recommended the use of multimodal analgesia incorporating preoperative nerve blocks for pain treatment after hip fracture.
In support of this recommendation, a randomized double-blind controlled trial of elderly patients suffering intertrochanteric and femur neck fractures conducted by Xufeng Lin et al. found that use of pericapsular nerve group (PENG) block, a novel technique that blocks the articular branches of the hip joint, resulted in significantly lower dynamic pain scores and lower opioid consumption (Reg Anesth Pain Med 2023;48:535-9).
When comparing PENG block with fascia iliaca compartment block in adult patients undergoing hip surgeries, Kalashetty et al. found that efficient preoperative analgesia that reduces the requirement for opioids and their negative side effects is crucial (Anesth Essays Res 2022;16:397-401). The study analyzed 90 participants undergoing hip surgeries in which fascia iliaca compartment block and PENG were administered before positioning patients for spinal anesthesia.
Researchers assessed Visual Analog Scale (VAS) scores at rest, with passive leg raise to 15 degrees before and after 30 minutes of the block. Blind observers also recorded hemodynamic parameters, including noninvasive blood pressure, respiratory rate, and heart rate. Results showed that patients who received PENG block outperformed the fascia iliaca compartment block group, indicating that it is a more effective analgesia.
An additional study by D-Yin Lin et al. confirmed these findings, showing that PENG block may provide better pain reduction while preserving motor function. Researchers assessed 60 patients in a single-center double-blinded randomized trial who presented for hip fracture and were treated with either femoral nerve block or pericapsular nerve group block (Reg Anesth Pain Med 2021;46:398-403). Results indicated that in postoperative recovery, patients treated with PENG block experienced less pain and that quadricep muscle strength was better preserved in the recovery unit.
Influencing future trends
Dr. Li shared that outcome research should be of primary focus when building future trends in care for patients with hip fractures. “The increased use of regional anesthesia and fewer opioids, plus early surgery and early physical therapy, will show a positive shift in patients’ recovery trajectories,” she said. “It is important to build multidisciplinary hip fracture care protocols that incorporate the use of motor-sparing, long-duration peripheral nerve blocks.”
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