Improving pain and function in hip fracture

在美国，髋部骨折是死亡率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， 对老年患者髋部骨折结局的影响不成比例地大于年轻成人。为 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的风险增加有关， 谵妄，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，术后6个月功能受损，住院费用增加。医生是 不愿意给老年患者开阿片类镇痛药以避免引起副作用（例如， 便秘，谵妄，镇静，恶心，呼吸抑制），研究表明，老年人接受 镇痛效果明显低于年轻人。 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， 在患者到达医院后立即进行区域技术的障碍 将这一选择限于小型研究。尽管如此，越来越多的证据表明疼痛是一种独立的 髋部骨折预后不良的危险因素，增加了老年患者有效镇痛策略的必要性。 成年人了本项目检查2个区域麻醉技术，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。60岁及以上的患者在两次纽约市急诊中就诊 髋部骨折的科室将随机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24小时内插入连续FIB导管， 单次注射FNB plus？根据需要？非阿片类/阿片类镇痛。住院病人将得到 常规治疗与定期安排静脉或口服阿片类药物加？根据需要？非/阿片类/阿片类。 我们将检查干预对患者自我报告的疼痛强度的影响;全身阿片类药物 要求;术后功能;谵妄发生率、治疗相关副作用;和住院时间 住院和参与物理治疗。

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.