Improving pain and function in hip fracture

描述(申请人提供)：在美国，髋部骨折是导致死亡和功能依赖的重要原因。无法控制的疼痛是髋部骨折后康复的主要障碍，而疼痛对老年患者髋部骨折预后的影响可能比年轻人大得不成比例。例如，疼痛可以诱发心动过速，增加心肌供氧需求，并产生心脏缺血。未经治疗的疼痛与术后并发症和精神错乱的风险增加有关，并已被证明会导致长时间卧床休息、行动不便、错过或缩短理疗疗程、手术后六个月功能受损以及医院费用增加。医生不愿给老年患者开阿片类止痛药，因为担心会产生副作用(如便秘、神志不清、镇静、恶心、呼吸抑制)，而且研究表明，老年人接受的止痛药明显少于年轻人。阿片类药物保留区域麻醉技术在老年人中是一种有吸引力的干预措施，但在患者被送到医院后立即采用区域技术的障碍限制了这种选择，仅限于小型研究。尽管如此，越来越多的证据表明疼痛是髋部骨折预后较差的独立危险因素，这增加了老年人有效止痛策略的必要性。本课题旨在探讨股神经阻滞(FNB)和髂筋膜阻滞(FIB)两种区域麻醉技术在治疗急性髋部(股骨颈、粗隆间)骨折疼痛中的作用和效果。60岁及以上到纽约市两个急诊科就诊的髋部骨折患者将随机接受干预或常规护理。干预措施包括在ED中单次注射FNB，然后在单次注射FNB后24小时内插入连续的FIB导管，并根据需要加用非阿片/阿片类止痛。常规护理患者将接受常规的静脉或口服阿片类药物治疗，并根据需要接受非/类阿片/类阿片类药物治疗。我们将研究干预措施对患者自我报告的疼痛强度、全身阿片类药物需求、术后功能、精神错乱的发生率、与治疗有关的副作用、住院时间和参与物理治疗的影响。

DESCRIPTION (provided by applicant): Hip fractures are an important cause of mortality and functional dependence in the United States. Uncontrolled pain is a major impediment to recovery following hip fracture and pain may have a disproportionately greater impact on hip fracture outcomes in geriatric patients than in younger adults. For example, pain can induce tachycardia, increase myocardial oxygen requirements, and produce cardiac ischemia. Untreated pain has been associated with an increased risk of post-operative complications and delirium and has been shown to lead to prolonged bed rest, delayed ambulation, missed or shortened physical therapy sessions, impaired function six months following surgery, and increased hospital costs. Physicians are reluctant to prescribe opioid analgesics to geriatric patients for fear of precipitating side effects (e.g., constipation, delirium, sedation, nausea, respiratory depression) and studies suggest that older adults receive significantly less analgesia than younger adults. Opioid sparing regional anaesthesia techniques represent an attractive intervention in older adults but barriers to undertaking regional techniques immediately upon presentation of patients to the hospital have limited this option to small research studies. Nonetheless, the increasing evidence of pain as an independent risk factor for poorer outcomes in hip fracture heightens the need for effective analgesic strategies for older adults. This project examines the efficacy and effects of 2 regional anesthesia techniques, femoral nerve blocks (FNB) and fascia iliaca blocks (FIB), on the treatment of peri-operative acute hip (femoral neck, intertrochanteric) fracture pain. Patients age 60 years and over presenting to two New York City emergency departments with hip fracture will be randomized to receive the intervention or usual care. The intervention includes single injection FNB in the ED followed by insertion of a continuous FIB catheter within 24 hours of the single injection FNB plus as needed non-opioid/opioid analgesia. Usual care patients will receive conventional therapy with regularly scheduled intravenous or oral opioids plus as needed non/opioids/opioids. We will examine the impact of the intervention on patients' self reported pain intensity; systemic opioid requirements; post-operative function; incidence of delirium, treatment related side effects; and hospital length of stay and participation in physical therapy.