Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial.
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ABSTRACT: To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture.Multisite randomized controlled trial from April 2009 to March 2013.Three New York hospitals.Individuals with hip fracture (N = 161).Participants were randomized to receive an ultrasound-guided, single-injection, femoral nerve block administered by emergency physicians at emergency department (ED) admission followed by placement of a continuous fascia iliaca block by anesthesiologists within 24 hours (n = 79) or conventional analgesics (n = 82).Pain (0-10 scale), distance walked on Postoperative Day (POD) 3, walking ability 6 weeks after discharge, opioid side effects.Pain scores 2 hours after ED presentation favored the intervention group over controls (3.5 vs 5.3, P = .002). Pain scores on POD 3 were significantly better for the intervention than the control group for pain at rest (2.9 vs 3.8, P = .005), with transfers out of bed (4.7 vs 5.9, P = .005), and with walking (4.1 vs 4.8, P = .002). Intervention participants walked significantly further than controls in 2 minutes on POD 3 (170.6 feet, 95% confidence interval (CI) = 109.3-232 vs 100.0 feet, 95% CI = 65.1-134.9; P = .04). At 6 weeks, intervention participants reported better walking and stair climbing ability (mean Functional Independence Measure locomotion score of 10.3 (95% CI = 9.6-11.0) vs 9.1 (95% CI = 8.2-10.0), P = .04). Intervention participants were significantly less likely to report opioid side effects (3% vs 12.4%, P = .03) and required 33% to 40% fewer parenteral morphine sulfate equivalents.Femoral nerve blocks performed by emergency physicians followed by continuous fascia iliaca blocks placed by anesthesiologists are feasible and result in superior outcomes.
Journal of the American Geriatrics Society 20161027 12
<h4>Objectives</h4>To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture.<h4>Design</h4>Multisite randomized controlled trial from April 2009 to March 2013.<h4>Setting</h4>Three New York hospitals.<h4>Participants</h4>Individuals with hip fracture (N = 161).<h4>Intervention</h4>Participants were randomized to receive an ultrasound-guided, single-injection, femoral nerve block administered by emergency physicians at emergency department (ED) admission ...[more]
Project description:Osteoporotic hip fracture is a major public health issue. Estimation of the outcome and maximization of functional recovery after fracture is very important in the treatment of older patients. The purposes of this study were to clarify the functional outcomes after the treatment of hip fracture and to identify the factors that influence functional recovery. In the present study, 228 patients admitted to an acute-care hospital from January 2016 to June 2018 were evaluated. The patients were categorized into a trochanteric fracture group (n = 128) and a neck fracture group (n = 100). We retrospectively reviewed their ambulation ability 6 months after fracture using the Functional Ambulation Category (FAC) score. The other survey items were the presurgical duration, length of hospital stay, time until beginning to walk using parallel bars, complications affecting treatment, and mortality rate. The 6-month follow-up rate was 54.4% (n = 124). The results showed that the patients with trochanteric fracture were significantly older than those with neck fracture (86 vs. 82 years, respectively; p = 0.03). In total, 85.0% of patients with trochanteric fracture and 92.2% of patients with neck fracture were independent ambulators before injury (FAC score of 4 or 5). The FAC score 6 months after fracture was positively correlated with the FAC score before fracture and at discharge (all p<0.001) and negatively correlated with patient age (p<0.001) and presurgical duration for patients with neck fracture (p = 0.04). There was no statistically significant correlation with the length of hospital stay or the time until beginning to walk using parallel bars. In conclusion, patients with trochanteric fractures were older than those with neck fractures. In both fracture types, walking recovery 6 months after hip fracture was related to the FAC score before injury and at discharge from an acute-care hospital but not to the time until beginning to walk using parallel bars.
Project description:BackgroundVarious nerve blocks with local anaesthetic agents have been used to reduce pain after hip fracture and subsequent surgery. This review was published originally in 1999 and was updated in 2001, 2002, 2009 and 2017.ObjectivesThis review focuses on the use of peripheral nerves blocks as preoperative analgesia, as postoperative analgesia or as a supplement to general anaesthesia for hip fracture surgery. We undertook the update to look for new studies and to update the methods to reflect Cochrane standards.Search methodsFor the updated review, we searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8), MEDLINE (Ovid SP, 1966 to August week 1 2016), Embase (Ovid SP, 1988 to 2016 August week 1) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to August week 1 2016), as well as trial registers and reference lists of relevant articles.Selection criteriaWe included randomized controlled trials (RCTs) involving use of nerve blocks as part of the care provided for adults aged 16 years and older with hip fracture.Data collection and analysisTwo review authors independently assessed new trials for inclusion, determined trial quality using the Cochrane tool and extracted data. When appropriate, we pooled results of outcome measures. We rated the quality of evidence according to the GRADE Working Group approach.Main resultsWe included 31 trials (1760 participants; 897 randomized to peripheral nerve blocks and 863 to no regional blockade). Results of eight trials with 373 participants show that peripheral nerve blocks reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.41, 95% confidence interval (CI) -2.14 to -0.67; equivalent to -3.4 on a scale from 0 to 10; I2 = 90%; high quality of evidence). Effect size was proportionate to the concentration of local anaesthetic used (P < 0.00001). Based on seven trials with 676 participants, we did not find a difference in the risk of acute confusional state (risk ratio (RR) 0.69, 95% CI 0.38 to 1.27; I2 = 48%; very low quality of evidence). Three trials with 131 participants reported decreased risk for pneumonia (RR 0.41, 95% CI 0.19 to 0.89; I2 = 3%; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 5 to 72; moderate quality of evidence). We did not find a difference in risk of myocardial ischaemia or death within six months, but the number of participants included was well below the optimal information size for these two outcomes. Two trials with 155 participants reported that peripheral nerve blocks also reduced time to first mobilization after surgery (mean difference -11.25 hours, 95% CI -14.34 to -8.15 hours; I2 = 52%; moderate quality of evidence). One trial with 75 participants indicated that the cost of analgesic drugs was lower when they were given as a single shot block (SMD -3.48, 95% CI -4.23 to -2.74; moderate quality of evidence).Authors' conclusionsHigh-quality evidence shows that regional blockade reduces pain on movement within 30 minutes after block placement. Moderate-quality evidence shows reduced risk for pneumonia, decreased time to first mobilization and cost reduction of the analgesic regimen (single shot blocks).
Project description:Systematic reviews associate peripheral nerve blocks based on anatomic landmarks or nerve stimulation with reduced pain and need for systemic analgesia in hip fracture patients. We aimed to investigate the effect of ultrasound-guided nerve blocks compared to conventional analgesia for preoperative pain management in hip fractures. Five databases were searched until June 2021 to identify randomised controlled trials. Two independent authors extracted data and assessed risk of bias. Data was pooled for meta-analysis and quality of evidence was evaluated using Grades of Recommendation Assessment, Development and Evaluation (GRADE). We included 12 trials (976 participants) comparing ultrasound-guided nerve blocks to conventional systemic analgesia. In favour of ultrasound, pain measured closest to two hours after block placement decreased with a mean difference of -2.26 (VAS 0 to 10); (p < 0.001) 95% CI [-2.97 to -1.55]. In favour of ultrasound, preoperative analgesic usage of iv. morphine equivalents in milligram decreased with a mean difference of -5.34 (p=0.003) 95% CI [-8.11 to -2.58]. Time from admission until surgery ranged from six hours to more than three days. Further, ultrasound-guided nerve blocks may be associated with a lower frequency of delirium: risk ratio 0.6 (p = 0.03) 95% CI [0.38 to 0.94], fewer serious adverse events: risk ratio 0.33 (p = 0.006) 95% CI [0.15 to 0.73] and higher patient satisfaction: mean difference 25.9 (VAS 0 to 100) (p < 0.001) 95% CI [19.74 to 32.07]. However, the quality of evidence was judged low or very low. In conclusion, despite low quality of evidence, ultrasound-guided blocks were associated with benefits compared to conventional systemic analgesia.
Project description:OBJECTIVES:To determine predictors of new activities of daily living (ADLs) disability and worsened mobility disability and secondarily increased daily care hours received, in previously independent hip fracture patients. DESIGN:Retrospective cohort study. SETTING:Academic hospital with ambulatory follow-up. PARTICIPANTS:Community-dwelling adults 65?years or older independent in ADLs undergoing hip fracture surgery in 2015 (n?=?184). MEASUREMENTS:Baseline, 3- and 6-month ADLs, mobility, and daily care hours received were ascertained by telephone survey and chart review. Comorbidities, medications, and characteristics of hospitalization were extracted from patient charts. Models for each outcome used logistic regression with a backward elimination strategy, adjusting a priori for age, sex, and race. RESULTS:Predictors of new ADL disability at 3?months were dementia (odds ratio [OR]?=?11.81; P?=?.001) and in-hospital delirium (OR?=?4.20; P?=?.002), and at 6 months were age (OR?=?1.04; P?=?.014), dementia (OR?=?9.91; P?=?.001), in-hospital delirium (OR?=?3.00; P?=?.031) and preadmission opiates (OR?=?7.72; P?=?.003). Predictors of worsened mobility at 3 months were in-hospital delirium (OR?=?4.48; P?=?.001) and number of medications (OR?=?1.13; P?=?.003), and at 6 months were age (OR?=?1.06; P?=?.001), preadmission opiates (OR?=?7.23; P?=?.005), in-hospital delirium (OR?=?3.10; P?=?.019), and number of medications (OR = 1.13; P?=?.013). Predictors of increased daily care hours received at 3 and 6 months were age (3 months: OR?= 1.07; P?=?.014; 6 months: OR?=?1.06; P?=?.017) and number of medications (3 months: OR?=?1.13; P?=?.004; 6 months: OR?=?1.22; P?=?.013). The proportion of patients with ADL disability and care hours received did not change from 3 to 6 months, yet there were significant improvements in mobility. CONCLUSION:Age, dementia, in-hospital delirium, number of medications, and preadmission opiate use were predictors of poor outcomes in independent older adults following hip fracture. Further investigation is needed to identify factors associated with improved mobility measures from 3 to 6 months to ultimately optimize recovery.
Project description:Little is known regarding outcomes after hip fracture among long-term nursing home residents.To describe patterns and predictors of mortality and functional decline in activities of daily living (ADLs) among nursing home residents after hip fracture.Retrospective cohort study of 60,111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fractures between July 1, 2005, and June 30, 2009.Data sources included Medicare claims and the Nursing Home Minimum Data Set. Main outcomes included death from any cause at 180 days after fracture and a composite outcome of death or new total dependence in locomotion at the latest available assessment within 180 days. Additional analyses described within-residents changes in function in 7 ADLs before and after fracture.Of 60,111 patients, 21,766 (36.2%) died by 180 days after fracture; among patients not totally dependent in locomotion at baseline, 53.5% died or developed new total dependence within 180 days. Within individual patients, function declined substantially after fracture across all ADL domains assessed. In adjusted analyses, the greatest decreases in survival after fracture occurred with age older than 90 years (vs ?75 years: hazard ratio [HR], 2.17; 95% CI, 2.09-2.26 [P?<?.001]), nonoperative fracture management (vs internal fixation: HR for death, 2.08; 95% CI, 2.01-2.15 [P?<?.001]), and advanced comorbidity (Charlson score of ?5 vs 0: HR, 1.66; 95% CI, 1.58-1.73 [P?<?.001]). The combined risk of death or new total dependence in locomotion within 180 days was greatest among patients with very severe cognitive impairment (vs intact cognition: relative risk [RR], 1.66; 95% CI, 1.56-1.77 [P?<?.001]), patients receiving nonoperative management (vs internal fixation: RR, 1.48; 95% CI, 1.45-1.51 [P?<?.001]), and patients older than 90 years (vs ?75 years: RR, 1.42; 95% CI, 1.37-1.46 [P?<?.001]).Survival and functional outcomes are poor after hip fracture among nursing home residents, particularly for patients receiving nonoperative management, the oldest old, and patients with multiple comorbidities and advanced cognitive impairment. Care planning should incorporate appropriate prognostic information related to outcomes in this population.
Project description:BackgroundRecent reports show substantial geographic variation in postacute health care spending. Little is known about variation in functional outcomes after postacute rehabilitation for patients with hip fracture. We examined variation in mobility and self-care after hip fracture rehabilitation across inpatient rehabilitation facilities (IRFs), hospital referral regions (HRRs) and states.MethodsRetrospective cohort study using data from the Centers for Medicare and Medicaid Services (CMS) from 2006 to 2009. Study sample included 149,258 records from patients 66 years and older at 1,166 IRFs located within 292 HRRs and across 50 states. Hip fracture cases were defined by CMS impairment group codes (08.11, 08.12). Hierarchical generalized linear models were used to assess discharge mobility and self-care functional status, adjusting for individual patient characteristics and the random effect of IRFs, HRRs, and states.ResultsVariation in discharge mobility status as assessed by the intraclass correlation percentage (ICC%) was 8.8% across IRFs, 4.0% across HRRs, and 1.8% across states. For self-care, the ICCs were 10.2% across IRFs, 4.8% across HRRs, and 2.4% across states. The range of discharge mobility scores (maximum functional status rating to minimum functional status rating) showed a 9.6-point difference for IRFs, 6.5 for regions, and 2.6 for states. Range of discharge self-care scores were 13.1 for IRFs, 6.8 for HRRs, and 3.4 for states.ConclusionVariation in functional status following postacute hip fracture rehabilitation appears to occur primarily at the level of facilities rather than geographic location.
Project description:BackgroundThe impact of gender on functional outcomes after hip fracture is not known. We aimed to determine the extent to which gender influenced functional outcome and response to exercise in older people after hip fracture, and to determine if any differences persisted after adjusting for cognition, weight and age.MethodSecondary analysis of data from the Enhancing Mobility After Hip Fracture trial in which older people after hip fracture received either a lower or higher intensity exercise program. Functional outcomes included physical performance and self-reported measures. Regression models were used to compare genders at baseline, week 4 and week 16, with adjustment for baseline values, cognition, weight and age. Interaction terms were used to assess a differential impact of the intervention by gender.ResultsOutcome data were available for 160 participants, 30 men (19%) and 130 women (81%) at baseline, with the withdrawal of 4 men (13%) and 6 women (5%) at week 16. There were no gender differences for any baseline measures or for most of the 19 functional outcome measures at weeks 4 and 16. At week 4 men performed better in knee extensor strength (2.1 kg, 95% CI 0.6 to 3.7, p < 0.01). This difference did not persist after adjustment for body weight, however persisted after adjusting for baseline, cognition, and age (p = 0.038). At week 4, men performed better in coordinated stability (-10.0 error score, 95% CI -17.6 to -2.4, p=0.010) and this persisted after adjusting for baseline values only but not for cognition and age (p = 0.073). At week 16, men performed better in coordinated stability (-10.2 error score, 95% CI -18.4 to -1.9, p=0.016) and this persisted after adjusting only for cognitive impairment (p = 0.029) but not for age and baseline (p = 0.135). There was no indication of a differential impact of intervention type on the basis of gender.ConclusionsA few between gender differences were observed in strength and balance, however these appeared to be confounded by body weight, age and/or cognition.
Project description:Hip arthroplasty frequently requires potent postoperative analgesia, often provided with an epidural or posterior lumbar plexus local anesthetic infusion. However, American Society of Regional Anesthesia guidelines now recommend against epidural and continuous posterior lumbar plexus blocks during administration of various perioperative anticoagulants often administered after hip arthroplasty. A continuous femoral nerve block is a possible analgesic alternative, but whether it provides comparable analgesia to a continuous posterior lumbar plexus block after hip arthroplasty remains unclear. We therefore tested the hypothesis that differing the catheter insertion site (femoral versus posterior lumbar plexus) after hip arthroplasty has no impact on postoperative analgesia.Preoperatively, subjects undergoing hip arthroplasty were randomly assigned to receive either a femoral or a posterior lumbar plexus stimulating catheter inserted 5 to 15 cm or 0 to 1 cm past the needle tip, respectively. Postoperatively, patients received perineural ropivacaine, 0.2% (basal 6 mL/hr, bolus 4 mL, 30-minute lockout) for at least 2 days. The primary end point was the average daily pain scores as measured with a numeric rating scale (0-10) recorded in the 24-hour period beginning at 07:30 the morning after surgery, excluding twice-daily physical therapy sessions. Secondary end points included pain during physical therapy, ambulatory distance, and supplemental analgesic requirements during the same 24-hour period, as well as satisfaction with analgesia during hospitalization.The mean (SD) pain scores for subjects receiving a femoral infusion (n = 25) were 3.6 (1.8) versus 3.5 (1.8) for patients receiving a posterior lumbar plexus infusion (n = 22), resulting in a group difference of 0.1 (95% confidence interval -0.9 to 1.2; P = 0.78). Because the confidence interval was within a prespecified -1.6 to 1.6 range, we conclude that the effect of the 2 analgesic techniques on postoperative pain was equivalent. Similarly, we detected no differences between the 2 treatments with respect to the secondary end points, with one exception: subjects with a femoral catheter ambulated a median (10th-90th percentiles) 2 (0-17) m the morning after surgery, in comparison with 11 (0-31) m for subjects with a posterior lumbar plexus catheter (data nonparametric; P = 0.02).After hip arthroplasty, a continuous femoral nerve block is an acceptable analgesic alternative to a continuous posterior lumbar plexus block when using a stimulating perineural catheter. However, early ambulatory ability suffers with a femoral infusion.
