Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California.
Department of Anesthesiology, Cedars Sinai Medical Center, Los Angeles, California.
J Bone Joint Surg Am. 2020 May 20;102(10):866-872. doi: 10.2106/JBJS.19.01148.
Fascia iliaca nerve blocks (FIBs) anesthetize the thigh and provide opioid-sparing analgesia for geriatric patients with hip fracture awaiting a surgical procedure. FIBs are recommended for preoperative pain management; yet, block administration is often delayed for hours after admission, and delays in pain management lead to worse outcomes. Our objective was to determine whether opioid consumption and pain following a hip fracture are affected by the time to block (TTB). We also examined length of stay and opioid-related adverse events.
This prospective cohort study included patients who were ≥60 years of age, presented with a hip fracture, and received a preoperative FIB from March 2017 to December 2017. Individualized care timelines, including the date and time of admission, block placement, and surgical procedure, were created to evaluate the effect that TTB and time to surgery (TTS) had on outcomes. Patterns among TTB, TTS, and morphine milligram equivalents (MME) were investigated using the Spearman rho correlation. For descriptive purposes, we divided patients into 2 groups based on the median TTB. Multivariable regression for preoperative MME and length of stay was performed to assess the effect of TTB.
There were 107 patients, with a mean age of 83.3 years, who received a preoperative FIB. The median TTB was 8.5 hours. Seventy-two percent of preoperative MME consumption occurred before block placement (pre-block MME). A longer TTB was most strongly correlated with pre-block MME (rho = 0.54; p < 0.001), and TTS was not correlated. Patients with a faster TTB consumed fewer opioids preoperatively (12.0 compared with 33.1 MME; p = 0.015), had lower visual analog scale scores for pain on postoperative day 1 (2.8 compared with 3.5 points; p = 0.046), and were discharged earlier (4.0 compared with 5.5 days; p = 0.039). There were no differences in preoperative pain scores, postoperative opioid consumption, delirium, or opioid-related adverse events. Multivariate regression showed that every hour of delay in TTB was associated with a 2.8% increase in preoperative MME and a 1.0% increase in the length of stay.
Faster TTB in geriatric patients with hip fracture may reduce opioid use, pain, and length of stay.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
股外侧皮神经阻滞（FIB）可麻醉大腿，并为等待手术的老年髋部骨折患者提供阿片类药物节省的镇痛作用。 FIB 推荐用于术前疼痛管理； 然而，阻滞的给药通常在入院数小时后延迟，并且疼痛管理的延迟导致更差的结果。我们的目的是确定股外侧皮神经阻滞的时间（TTB）是否会影响髋部骨折后的阿片类药物消耗和疼痛。我们还检查了住院时间和阿片类药物相关的不良事件。
本前瞻性队列研究包括年龄≥60 岁的患者，他们因髋部骨折就诊，并于 2017 年 3 月至 2017 年 12 月接受了术前 FIB。创建个体化护理时间表，包括入院日期和时间，阻滞放置和手术程序，以评估 TTB 和手术时间（TTS）对结果的影响。使用 Spearman rho 相关性研究 TTB，TTS 和吗啡毫克当量（MME）之间的关系。出于描述目的，我们根据中位数 TTB 将患者分为 2 组。进行术前 MME 和住院时间的多变量回归，以评估 TTB 的影响。
共有 107 例患者，平均年龄为 83.3 岁，接受了术前 FIB。中位 TTB 为 8.5 小时。术前 MME 消耗的 72％发生在阻滞放置之前（阻滞前 MME）。较长的 TTB 与阻滞前 MME 的相关性最强（rho = 0.54；p <0.001），而 TTS 则没有相关性。TTB 较快的患者术前阿片类药物消耗较少（12.0 与 33.1 MME；p = 0.015），术后第 1 天疼痛的视觉模拟量表评分较低（2.8 与 3.5 分；p = 0.046），并且出院较早（4.0 与 5.5 天；p = 0.039）。术前疼痛评分，术后阿片类药物消耗，谵妄或阿片类药物相关不良事件无差异。多变量回归显示，TTB 每延迟一小时，术前 MME 增加 2.8％，住院时间增加 1.0％。
髋部骨折的老年患者更快的 TTB 可能会减少阿片类药物的使用，减轻疼痛并缩短住院时间。
治疗水平 IV。 请参阅作者说明，以获取完整的证据水平描述。
