Hip fractures are a frequent cause of morbidity and mortality in the elderly, with a rate of 7-8/1000 in Wisconsin residents over the age of 65 in the year 2007.1 Inadequate analgesia in this group of patients stems from lack of effective assessment tools and concerns about risks of opioid related side effects.2,3 Physicians and nurses fear precipitating delirium, sedation, respiratory depression, nausea and constipation in the elderly when using opioids. It has been suggested that opioid sparing analgesia should be encouraged in the elderly to reduce side effects.
Several studies have been performed which examine pain control of hip fracture patients in the emergency department (ED).4-7 It has been found that pain control is improved with the placement of a femoral nerve block (FNB) or fascia iliaca block. These nerve blocks are performed by delivering local anesthetic in the area around the femoral nerve, thus ‘numbing’ a large portion of the femur. One study from Sweden looked at the relationship between a FNB placed in the emergency department (ED) and time to “mobilization” following surgery.7 They found that it took 12 fewer hours to “mobilize” patients and that there was less confusion, among those who received a FNB.
We have performed a chart review of 26 hip fracture patients treated at the University of Wisconsin Hospital and Clinics during 2009. We did this to document what the current state of pain control is in elderly hip fracture patients. The worst pain scores for these patients was found pre-operatively, and specifically in the ED. Median ED pain scores at rest were 4.8 (range 0-10) and with activity the median was 9 (range 5.5-10). We also found that on post-operative day 1 half of the notes from physical therapy commented that patient participation was impaired by pain, with 2/26 patients unable to participate at all due to sedation. Based on this we feel any intervention we initiate needs to begin the in the ED and extend into the post-operative period.
The goal of this quality initiative is to improve pain control and outcomes in patients with hip fractures.
Any patient presenting to the UW ED on weekdays during the hours of 7am to 5pm with an isolated hip fracture, normal distal neurovascular exam, who is able to consent to the procedure and participate in pain evaluations is eligible to be included in this study.
Upon identification of the patient a consult order to the anesthesia pain and blocks resident will be entered. The contact number will be the acute pain resident at (608) 235-1428 or blocks resident at (608) 516-6291.
The anesthesia resident will obtain consent for the procedure and complete a procedure note in the Health Link system. He/she will record the number of attempts made and any complications (vascular puncture, nerve puncture, and hematoma).
Time to completion of the block will be measured from the time of the initial consultation until completion of the procedure.
Pain scores will be assessed at identification of the patient, immediately before the procedure, and then 15 minutes, 30 minutes and hourly after completion of the procedure until leaving the ED.
The amount of analgesia medication required both before and after the procedure will be recorded.
1. Wisconsin Department of Health Services, Health Statistics. http://dhs.wisconsin.gov/stats/
2. Morrison RS, Magaziner J, McLaughlin MA, Orosz G, Silberzweig SB, Koval KJ, Siu AL. The impact of post-operative pain on outcomes following hip fracture. Pain. 2003;103:303-311
3. Aubrun F, Marmion F. The elderly patient and postoperative pain treatment. Best Practice and Research Clinical Anesthesiology. 2007;21:109-127.
4. Beaudoin FL, Nagdev A, Merchant RC, Becker BM. Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures. Am J Emerg Med. 2007;25:472-475.
5. Fletcher AK, Rigby AS, Heyes FL. Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: A randomized, controlled trial. Ann Emerg Med. 2003;41:227-233.
6. Foss NB, Kristensen BB, Bundgaard M, Bak M, Heiring C, Virkelyst C, Hougaard S, Kehlet H. Fascia iliaca compartment blockade for acute pain control in hip fracture patients. Anesthesiology. 2007;106:773-778.
7. Kullengerg B, Ysberg B, Heilman M, Resch S. Femoral nerve block as pain relief in hip fracture. A good alternative in perioperative treatment provided by a prospective study. Lakartidningen. 2004;101:2104-2107.