Fabi David W
Scripps Mercy Hospital, San Diego, CA.
J Orthop Trauma. 2016 May;30 Suppl 1:S6-S11. doi: 10.1097/BOT.0000000000000561.
Hip fracture is one of the most common injuries among the elderly and, because the population is aging, it is expected to remain a major clinical challenge and public health problem for the foreseeable future. The clinical importance of early mobilization and prompt participation in physical therapy after hip fracture surgery is now widely recognized. Because postoperative pain can impair mobility and delay physical therapy, much attention is now being paid to finding more effective ways of controlling pain after hip fracture. Oversedation with opioid drugs inhibits communication between the patient and the health care team, can delay ambulation and rehabilitation therapy, and may increase the probability of the patient requiring a skilled nursing facility, which adds further cost to the overall health care system. Multiple pain pathways contribute to the perception of postoperative pain, and although opioids are highly effective in blocking nociceptive pain through inhibition of the mu receptors, they do not block other pain pathways. Multimodal analgesia involves the use of several anesthetic and analgesic modalities that are strategically combined to block pain perception at different sites in the peripheral and central nervous systems. This balanced, multifaceted approach provides more effective control of postoperative pain than opioid drugs alone, allows lower doses of opioids to be used as part of the multimodal regimen (thereby reducing the risk of opioid-related adverse events and complications), and may facilitate more rapid recovery and improve certain outcome measures related to recovery time. One prospective randomized study evaluating the clinical value of multimodal pain management in elderly patients undergoing bipolar hip hemiarthroplasty found that a multimodal regimen, including preemptive pain medication and intraoperative periarticular injections, reduced pain on postoperative days 1 and 4, and reduced overall opioid use. This article describes an effective multimodal pain management regimen for hip fracture patients.
髋部骨折是老年人中最常见的损伤之一，并且由于人口老龄化，在可预见的未来，它仍将是一项重大的临床挑战和公共卫生问题。髋部骨折手术后早期活动和及时参与物理治疗的临床重要性现已得到广泛认可。由于术后疼痛会损害活动能力并延迟物理治疗，目前人们非常关注寻找更有效的控制髋部骨折后疼痛的方法。阿片类药物使用过量会抑制患者与医护团队之间的沟通，可能延迟步行和康复治疗，并可能增加患者需要专业护理机构护理的可能性，这会给整个医疗保健系统增加更多成本。多种疼痛传导途径导致术后疼痛的感知，尽管阿片类药物通过抑制μ受体在阻断伤害性疼痛方面非常有效，但它们并不能阻断其他疼痛传导途径。多模式镇痛涉及使用几种麻醉和镇痛方式，这些方式经过策略性组合，以在周围和中枢神经系统的不同部位阻断疼痛感知。这种平衡、多方面的方法比单独使用阿片类药物能更有效地控制术后疼痛，允许在多模式治疗方案中使用较低剂量的阿片类药物（从而降低与阿片类药物相关的不良事件和并发症的风险），并且可能有助于更快恢复并改善与恢复时间相关的某些结果指标。一项评估多模式疼痛管理在接受双极髋半关节置换术的老年患者中的临床价值的前瞻性随机研究发现，包括预防性疼痛药物和术中关节周围注射在内的多模式治疗方案，可减轻术后第1天和第4天的疼痛，并减少阿片类药物的总体使用量。本文描述了一种针对髋部骨折患者的有效的多模式疼痛管理方案。
