Early Regional Anesthesia with Multimodal Pain Management in Geriatric Hip Fractures: A Protocol to Reduce Opioid Use
John Garlich, MD, Zachary Moak, MD, Eytan Debbi, MD,, Raj Yalamanchili, MD, Sam Stephenson, MD, Stephen Stephan, MD, Milton Little, MD, Kapil Anand, MD, Charles Moon, MD, Mark Vrahas, MD, Donald Wiss, MD, Carol Lin, MD
Pain management in the geriatric population is difficult because of concerns for delirium which can be caused both by opioids as well as uncontrolled pain. Up to 40% of hip fracture patients experience delirium. Additionally, elderly patients are at increased risk of other opioid-associated adverse effects including urinary retention, pulmonary complications, constipation, long term addiction, and abuse. Previous studies have reported a daily consumption of opioids in these patients of 20-50mg of morphine equivalents. We sought to implement a multidisciplinary multimodal pain management strategy to reduce opioid consumption in geriatric hip fracture patients
From March 2017 – November 2017 hip fracture patients 60 and over were enrolled in a comprehensive hip fracture pain management program at an urban Level 1 academic trauma center. Upon diagnosis, patients underwent a continuous or single-shot fascia iliaca block (FIB) in the emergency room by the regional anesthesia team. Block administration times were recorded and compared to Emergency Department admission times to determine the average time to block for each patient. Patients were then placed on a standardized regimen of scheduled meloxicam and acetaminophen, with additional tramadol and IV dilaudid as needed. Patients underwent operative hip fracture management per the standard of care. All patients were mobilized with full weight bearing after surgery. Complications, hospital stay, and opioid usage converted to morphine-equivalents was recorded.
Of the 177 patients presenting with a hip fracture, a total of 84 patients (47.5%) received a block preoperatively and were included for final review. The average age was 83.6 years ± 8.7, the median time to preoperative fascia iliaca block placement was 8.3 [4.5 – 15.3] hrs. The median time from admission to surgery was 1.0 [0.9 – 1.4] days. The median length of stay was 4.7 [3.6 – 6.6] days. The incidence of delirium was 22.6% (19/84). The overall rate of opioid-related adverse events was 19.0% (16/84) and included constipation (5), urinary retention (7), and urinary tract infections (4). No patients required naloxone for respiratory depression. Morphine equivalent dose consumption was recorded for the entire preoperative period, including opioid consumption before block placement. During the preoperative period, total MED/day consumption was 21.6 [10.2 – 41.3] mg/day. MED usage significantly decreased Pre-Block to Post-Block: mean ± sd = 24.4 ± 25.2 to 11.8 ± 18.9, median [Q1-Q3] = 16.1 [6 – 38.6] to 0 [0 – 13.7], P < 0.0001 for each comparison. After accounting for time, MED/hr significantly decreased Pre-Block to Post-Block: mean ± sd = 2.7 ± 2.9 to 0.6 ± 0.9, median [Q1 – Q3] = 2.1 [0.8 – 3.2] to 0.0 [ 0.0 – 0.9], P < 0.0001 for each comparison. A Wilcoxon Signed Rank-Test shows a significant decrease between pre- and post-block MED/hr [∆ = -2.03 ± 2.73 mg/hr, CI -2.6 to -1.4 (p-value <0.0001)].
Our study shows that preoperative fascia iliaca blocks significantly reduce preoperative hourly morphine equivalent consumption when compared to pre-block opioid consumption. Additionally, we had no complications from block placement, and patients could proceed with a standardized weight-bearing mobilization protocol. Our rates of postoperative morphine equivalent consumption, opioid-related adverse events, delirium, and length of stay are consistent with current literature.
We prospectively recorded the type and time of block placement to accurately assess the effect of a fascia iliaca block on opioid consumption during the entire hospital stay. To our knowledge, this is the first study to describe the decrease in hourly preoperative opioid consumption after block placement. The need to decrease the initial opioid load at the time of injury is critical; as increased opioid use at the time of injury is associated with a higher likelihood of long-term opioid use.1-4
Our patients had a median postoperative morphine equivalent consumption of 15.0 [0 – 30] and 6.0 [0 – 24] mg on postoperative days 1 and 2, respectively. This data is consistent with previous studies evaluating fascia iliaca blocks and postoperative morphine consumption, ranging from 3.2 – 10.5 mg/day.5-8 Although we used a specific pain regimen for each patient, if a patient’s pain was inadequately controlled, providers could change the medications at their discretion. The variability in provider prescribing patterns and implementation of a new medication regimen may have created the slightly higher opioid consumption, seen on postoperative day one, compared to previous studies.
Prior reports have shown that fascia iliaca blocks may reduce opioid-related adverse events as well as the length of stay.5,8 There were 16 (19%) opioid-related adverse events, and no patients required naloxone for respiratory depression in our cohort. The median length of stay was 4.7 [3.6 – 6.6] days. Our rate of opioid adverse events and length of stay are comparable to rates reported in the literature.7,8
The rate of delirium in our study was 22.6% (19/84) which is similar to delirium rates reported in hip fracture patients treated with and without fascia iliaca blocks, ranging from 10.8% to 61%.9,10
In conclusion, our study reports the perioperative consumption of opioids, incidence of delirium, and opioid-related adverse events in all hip fracture patients treated with both single-shot and continuous fascia iliaca blocks. Our results suggest that regional anesthesia, as part of a comprehensive multimodal pain management strategy, can lower the rate of preoperative opioid consumption and should be strongly considered for geriatric hip fracture patients, particularly those at risk for delirium and other opioid-related complications.
1. Barnett ML, Olenski AR, Jena AB. Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use. N Engl J Med. 2017 Feb 16;376(7):663-73.
2. Calcaterra SL, Yamashita TE, Min SJ, Keniston A, Frank JW, Binswanger IA. Opioid Prescribing at Hospital Discharge Contributes to Chronic Opioid Use. J Gen Intern Med. 2016 May;31(5):478-85.
3. Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014 Feb 11;348:g1251.
4. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012 Mar 12;172(5):425-30.
5. Nie H, Yang YX, Wang Y, Liu Y, Zhao B, Luan B. Effects of continuous fascia iliaca compartment blocks for postoperative analgesia in hip fracture patients. Pain Res Manag. 2015 Jul-Aug;20(4):210-2.
6. Chaudet A, Bouhours G, Rineau E, Hamel JF, Leblanc D, Steiger V, et al. Impact of preoperative continuous femoral blockades on morphine consumption and morphine side effects in hip-fracture patients: A randomized, placebo-controlled study. Anaesth Crit Care Pain Med. 2016 Feb;35(1):37-43.
7. Callear J, Shah K. Analgesia in hip fractures. Do fascia-iliac blocks make any difference? BMJ Qual Improv Rep. 2016;5(1).
8. Arsoy D, Gardner MJ, Amanatullah DF, Huddleston JI, 3rd, Goodman SB, Maloney WJ, et al. Continuous Femoral Nerve Catheters Decrease Opioid-Related Side Effects and Increase Home Disposition Rates Among Geriatric Hip Fracture Patients. J Orthop Trauma. 2017 Jun;31(6):e186-e9. Epub 2017/05/26.
9.Sieber FE, Zakriya KJ, Gottschalk A, Blute MR, Lee HB, Rosenberg PB, et al. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc. 2010 Jan;85(1):18-26.
10.Gruber-Baldini AL, Zimmerman S, Morrison RS, Grattan LM, Hebel JR, Dolan MM, et al. Cognitive impairment in hip fracture patients: timing of detection and longitudinal follow-up. J Am Geriatr Soc. 2003 Sep;51(9):1227-36.