Improving pain and function in hip fracture

描述（由申请人提供）：在美国，髋部骨折是死亡和功能依赖的重要原因。不受控制的疼痛是髋部骨折后恢复的主要障碍，疼痛对老年患者髋部骨折结局的影响可能比年轻人大得多。例如，疼痛可诱发心动过速，增加心肌氧需求，并产生心脏缺血。未经治疗的疼痛与术后并发症和谵妄的风险增加有关，并已被证明会导致长期卧床休息，延迟截肢，错过或缩短物理治疗疗程，手术后6个月功能受损，以及住院费用增加。医生不愿意给老年患者开阿片类镇痛药，因为担心会产生副作用（例如，便秘、谵妄、镇静、恶心、呼吸抑制），并且研究表明老年人比年轻人接受显著更少的镇痛。保留阿片类药物的区域麻醉技术在老年人中是一种有吸引力的干预措施，但在将患者送到医院后立即进行区域技术的障碍将这种选择限制在小型研究中。尽管如此，越来越多的证据表明疼痛是髋部骨折不良结局的独立危险因素，这就需要对老年人采取有效的镇痛策略。本项目研究了两种区域麻醉技术，股神经阻滞（FNB）和髂筋膜阻滞（FIB）治疗围手术期急性髋关节（股骨颈，转子间）骨折疼痛的有效性和效果。年龄60岁及以上的髋部骨折患者在纽约市的两个急诊科就诊，将被随机分配接受干预或常规护理。干预包括在艾德中单次注射FNB，然后在单次注射FNB后24小时内插入连续FIB导管，并根据需要进行非阿片类/阿片类镇痛。家庭护理患者将接受常规治疗，定期静脉注射或口服阿片类药物，根据需要加非阿片类药物/阿片类药物。我们将研究干预对患者自我报告的疼痛强度的影响;全身阿片类药物需求;术后功能;谵妄的发生率，治疗相关的副作用;住院时间和参与物理治疗。

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.