囊外和囊内髋关节骨折手术中使用脂质体布比卡因进行多模式疼痛管理的当前实践：专家小组意见。
Current Practices for Multimodal Pain Management Using Liposomal Bupivacaine in Extracapsular and Intracapsular Hip Fracture Surgery: Expert Panel Opinion.
机构信息
Department of Orthopedic Surgery, Loma Linda University, Loma Linda, CA.
Tallahassee Orthopedic Clinic, Tallahassee, FL.
出版信息
J Orthop Trauma. 2018 Aug;32 Suppl 2:S1-S4. doi: 10.1097/BOT.0000000000001226.
BACKGROUND
Liposomal bupivacaine (LB) has demonstrated efficacy across a range of surgical settings, including shoulder, knee, and hip surgery. However, data are limited on the use of LB as part of a multimodal pain management approach in hip fracture surgery.
METHODS
On April 1, 2017, 4 orthopaedic surgeons and 3 anesthesiologists convened to discuss current practices and develop a consensus statement related to local infiltration analgesia with LB for hip fracture surgical procedures within the context of a multimodal opioid-sparing pain management approach. Separate workshops addressed intracapsular and extracapsular hip fracture surgery.
RESULTS
Multimodal strategies before, during, and after hip fracture surgery are paramount to optimizing pain control and minimizing opioid requirements. LB infiltration should occur intraoperatively near the time of closing the incision. For both intracapsular and extracapsular procedures, oral or intravenous acetaminophen, a nonsteroidal anti-inflammatory drug (NSAID) of choice, and tramadol should be given preoperatively. Presurgical fascia iliaca block with bupivacaine HCl may help bridge the period before LB takes effect. After both procedures, patients should receive 1 dose of intravenous acetaminophen, an NSAID, and opioid rescue medication as needed, starting with tramadol. Postoperative NSAIDs may help minimize opioid use. Patient and provider education are integral to managing patient expectations and alleviating concerns about pain and opioid use. Standardized, validated, and appropriately timed pain assessments are also necessary to optimize postsurgical pain management.
CONCLUSIONS
These consensus recommendations regarding multimodal pain management protocols incorporating local infiltration analgesia with LB for extracapsular and intracapsular hip fracture procedures serve as a basis for additional research.
LEVEL OF EVIDENCE
Level V.
背景
脂质体布比卡因（LB）在多种手术环境中均显示出疗效，包括肩部、膝部和髋部手术。然而，在髋部骨折手术中，将 LB 作为多模式疼痛管理方法的一部分的数据有限。
方法
2017 年 4 月 1 日，4 名骨科医生和 3 名麻醉师聚集在一起，讨论当前的实践，并在多模式阿片类药物节约疼痛管理方法的背景下，就 LB 用于髋部骨折手术的局部浸润镇痛达成共识声明。单独的研讨会讨论了囊内和囊外髋部骨折手术。
结果
髋部骨折手术前后的多模式策略对于优化疼痛控制和最小化阿片类药物需求至关重要。LB 浸润应在手术期间接近关闭切口时进行。对于囊内和囊外手术，应在术前给予口服或静脉注射对乙酰氨基酚、首选的非甾体抗炎药（NSAID）和曲马多。在接受手术前，可进行股神经髂筋膜阻滞，以帮助缓解 LB 起效前的时间。在这两种手术之后，患者应根据需要接受 1 剂静脉注射对乙酰氨基酚、NSAID 和阿片类药物解救药物，起始药物为曲马多。术后 NSAID 可能有助于减少阿片类药物的使用。患者和医务人员的教育是管理患者期望和减轻对疼痛和阿片类药物使用的担忧的重要组成部分。标准化、验证和适当定时的疼痛评估对于优化术后疼痛管理也是必要的。
结论
这些关于多模式疼痛管理方案的共识建议，包括在囊外和囊内髋部骨折手术中使用 LB 局部浸润镇痛，为进一步的研究提供了基础。
证据水平
5 级。
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