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Elderly patients with hip fracture experience high morbidity and mortality, and are often undertreated for pain. Acute pain management in the elderly is challenging, with physiological frailty, medical comorbidities and cognitive impairment commonly compounding pain assessment and treatment. Guidelines outlining current best practice for acute pain management in the elderly now exist, but evidence suggests that practice remains variable and there continues to be scope for improvement. We conducted a narrative review of the literature to examine the challenges of acute pain management in the elderly, and to evaluate evidence for the role of regional nerve blocks for acute pain associated with hip fracture in the elderly. There is consistent evidence that regional nerve blocks can effectively reduce pain associated with hip fracture, providing rapid-onset, site-specific analgesia that is more effective than standard systemic analgesia alone. There is also moderate evidence that nerve blocks may contribute to reduced rates of delirium, and some suggestion of reduced length of inpatient stay, morbidity and mortality, although limited evidence is available. Fascia iliaca blocks are emerging as a block of choice, with evidence they can be safely and rapidly administered under ultrasound guidance in the acute setting, by both trained medical and nursing staff, with good effect. Ideally, comprehensive pain protocols for elderly hip fracture patients are required, that integrate evidence-based fascia iliaca block use, timely and repeated pain assessment, and multidisciplinary orthogeriatric patient care. [ABSTRACT FROM AUTHOR]

We performed a single centre, double blind, randomised, controlled, non-inferiority study comparing ultrasound-guided fascia iliaca block with spinal morphine for the primary outcome of 24-h postoperative morphine consumption in patients undergoing primary total hip arthroplasty under spinal anaesthesia with levobupivacaine. One hundred and eight patients were randomly allocated to receive either ultrasound-guided fascia iliaca block with 2 mg.kg-1 levobupivacaine (fascia iliaca group) or spinal morphine 100 μg plus a sham ultrasound-guided fascia iliaca block using saline (spinal morphine group). The pre-defined non-inferiority margin was a median difference between the groups of 10 mg in cumulative intravenous morphine use in the first 24 h postoperatively. Patients in the fascia iliaca group received 25 mg more intravenous morphine than patients in the spinal morphine group (95% CI 9.0-30.5 mg, p < 0.001). Ultrasound-guided fascia iliaca block was significantly worse than spinal morphine in the provision of analgesia in the first 24 h after total hip arthroplasty. No increase in side-effects was noted in the spinal morphine group but the study was not powered to investigate all secondary outcomes. [ABSTRACT FROM AUTHOR]

The article presents Peripheral nerve block for hip fracture. Topics discussed include this is nearly as many hospitalizations as those for myocardial infarction or stroke among that same population and outnumbered hospitalizations for all other fractures combined; and the Cochrane review summarized here included all parallel randomized controlled trials (RCTs) and cluster RCTs comparing PNB versus sham block or no block among adult patients with hip fracture.

Objective: Femoral nerve blocks (FNBs) are commonly administered to patients with a fractured neck of femur (NOF). FNBs reduce complications associated with opioids and are effective for up to 24 h. However, the recognised 'gold standard' time to definitive treatment (surgery) in the patient with a fractured NOF is within 48 h. This leaves a significant period of time in which the patient has no effective analgesia, and might require opioids to alleviate pain. The present study explored the number of NOF patients who received a FNB: their wait for definitive treatment (surgery) and how much opioid analgesia was administered in the preoperative phase. Methods: A retrospective review of electronic patient records was conducted over a 6 month period in 2012. Patients who presented to the ED with a fractured NOF, received a FNB and were transferred to surgery in the same hospital were included in the sample. Results: The median time from FNBs to surgery was 37.5 h. When patients waited more than 20 h for surgery, the volume of opioid received increased significantly (P < 0.001). Conclusion: Even when patients' time to surgery was within the 'gold standard', patients received increasing doses of opioids 20 h after the administration of the FNB. While patients continue to wait extended periods for surgery, the practice of administering a single injection FNB needs to be challenged. ED clinicians might consider FNB infusions rather than single injection FNBs for patients with a fractured NOF. [ABSTRACT FROM AUTHOR]