Preoperative Continuous Peripheral Nerve Blocks in Hip Fracture Patients

By Stuart Grant, MB, ChB, FRCA, Gavin Martin, MB, ChB, FRCA, and Ellen Flanagan, MD    Oct 5, 2016
  • Stuart Grant, MB, ChB, FRCA

    Each year, at least 250,000 older people—those 65 years and older—are hospitalized for hip fractures.
  • More than 95% of hip fractures are caused by falling, usually by falling sideways.
  • Women experience threequarters of all hip fractures.
  • Women more often have osteoporosis.
  • Fall prevention programs are
    important.

Gavin Martin, MB, ChB, FRCA

When developing a plan to care for elderly patients with hip fractures, amassing a multidisciplinary team is the first step. With all stakeholders present charting the patient’s journey from arrival to discharge, a discussion of all areas of care and opportunities to reduce unwanted variability and improve care can take place.

As anesthesiologists working on the care improvement team, we had heard discussion about the severe pain many of these patients have to endure from arrival in the emergency room (ER) to continuation in other areas such as the X-ray suite, which we do not normally consider. As acute pain specialists with interests in regional anesthesia, we felt we could offer a better quality patient experience if we placed peripheral nerve catheters in these patients as soon as they arrived in the ER. In a previous review, Riddell et al[1] examined the use of femoral nerve blocks in the ER. Both single-shot and catheter techniques have shown benefit by reducing

Ellen Flanagan, MD

pain scores and opioid consumption. Additionally, reductions in respiratory and cardiac side effects have been noted without any increase in any adverse events.

In collaboration with ER colleagues, we developed a plan to call anesthesiology as soon as a hip fracture was diagnosed. We used an electronic order set, which is triggered by the ER provider when the orthopedic surgeon is called.

The thought of taking on another off-service burden was something that was met with some resistance by a minority of colleagues. We all consider ourselves to be busy all the time, but when we analyzed the total number of patients with hip fractures who are admitted each year, we realized that this was not going to be an overwhelming burden for any individual provider and that it would be a huge benefit to individual patients. The calls would be taken by all providers who covered in-house calls within our institution. Colleagues not on the acute pain service expressed reservations about their ability to actually perform the blocks. To address this issue, we created an education program,


“When developing a plan to care for elderly patients with hip fractures, amassing a multidisciplinary team is the first step.”


which was delivered repeatedly to colleagues through didactics and online education. Support was offered to ensure that everyone who might be called to provide this service could comfortably meet the expectations. One of the ways this was done was to provide direct clinical support during weekday calls for these catheters. An acute pain faculty member would accompany a generalist when he or she was placing femoral nerve catheters. In this way, the faculty member could answer questions and provide technical support for this procedure to improve the comfort level and expertise of all anesthesiologists in the department.

In addition, each day our anesthesia technicians ensured that all the equipment necessary was loaded into a bag stored beside the ultrasound machine. The bag contained our peripheral nerve catheter kits, ultrasound gel, consent form (for the nerve block and the surgery the next day), and a check list of all required equipment. Drugs cannot be stocked in the bag per regulations of the Centers for Medicare and Medicaid Services (CMS) and still have to be added from pharmacy before departure for the ER. The stocked bag and checklist minimized inconvenience to the patient as well as off-service providers who have to travel off-site and do not realize what equipment is missing until they arrive in the ER.

Figure 1: Step-by-step, laminated instructions of how to do the block were laminated and attached to the ultrasound unit used for ER blocks.

Additionally, step-by-step instructions (Figure 1) of how to do the block were laminated and attached to the ultrasound unit used for ER blocks. It is critical that the step-by-step instructions include specific instructions about site marking a block time-out. These will not be common practice for the off-service (ie, non–acute pain service) anesthesiologists so must be emphasized and explained within the instructions. 

After a block time-out, a femoral nerve catheter is placed. Lidocaine infiltration in the skin is followed by catheter placement. Local anesthetic is placed through the needle or catheter. The catheter is for analgesia. We use 0.2% ropivacaine 20 mL (0.25% bupivacaine 20 mL is also appropriate) with 1 in 400,000 epinephrine added as a marker for intravascular injection. A low concentration of local anesthetic has been selected because our goal is an analgesic block; a low concentration in a nutritionally depleted patient is likely a safer choice as well. Following placement of the initial bolus, an infusion of 6–8 mL/hr of 0.2% ropivacaine is commenced and continued until arrival in preoperative holding. Patient follow-up and management by an acute pain service is critical to ensuring appropriate management of the nerve catheter. The acute pain service manages the pain medications in coordination with the floor staff, including a step-down analgesia plan for when the peripheral nerve catheter is removed.

The peripheral nerve catheter is not used in isolation but as part of a comprehensive multimodal analgesia plan including scheduled—not as-needed—prescriptions of nonopioid analgesics. The patient’s medication record should be reviewed as part of the initial assessment, and coanalgesics should be optimized as patient health permits. Acetaminophen, celecoxib, and a gabapentanoid are our first-choice agents. Celecoxib should be used with caution
in dehydrated patients, especially in the presence of elevated creatinine.

We use our visit with the patient and family in the ER as an opportunity to perform a preoperative evaluation for the block and also for surgery. The ability to meet family and discuss anesthesia before the day of surgery seems to optimize our relationship with family and gives us an opportunity to provide guidance on how to optimize the patients medically. If we identify issues that need to be resolved before surgery, the patient can be fed and not held NPO for extended periods of time unnecessarily.

Generally, all hospitals attempt to minimize the time from admission to the time of surgery as best practice in hip fracture care. Despite that effort, the sickest patients may have a prolonged wait time before surgery. This is the most vulnerable group of patients but also the group that likely achieves the most benefit from this pain pathway.
At arrival in the preoperative holding area before surgery, a bolus of local anesthetic is delivered through the catheter before anything else is done. The bolus of local anesthetic deepens the block and permits more comfort for the patient before placement on his or her side for spinal anesthesia.

At surgery, spinal anesthesia is used wherever possible. Ultrasonography can prove very helpful in elderly patients to
assist with spinal placement. The authors have found L5–S1 space using ultrasonography many times where other colleagues have struggled to place a spinal. Careful dose reduction in spinal anesthesia is important in elderly patients (5–7.5 mg). A recent article examined the minimal doses of spinal local anesthetic for hip fracture when using titration via a spinal catheter.[2] Using the Dixon Massey method, the authors found that doses as low as 0.24 mL of 0.5% isobaric bupivacaine may be all that is required initially. The cumulative dose was just over 1 mL of 0.5% isobaric bupivacaine. This dose is much lower than is normally given by most practitioners. With their low dose, they found less hypotension than previously reported with larger doses of local anesthetic. 

As part of the time-out at surgery, a discussion should occur about keeping the peripheral nerve catheter or pulling it. The catheter should be pulled in the operating room if there is a realistic expectation that the patient will ambulate on the day of surgery. If the patient is very frail and was not ambulating independently before surgery or is not likely to ambulate the day of surgery, consider keeping the catheter running for postoperative analgesia.

One issue that has come up on occasion is our inability to always immediately attend to these patients in the ER as soon as we are called. Since this is covered by the on-call team, sometimes emergencies require the team members to delay placement of a catheter until their emergent obligations lessen. This has occurred a very small number of times but can happen when using this model of staff coverage. With the initiation of this program, we also had to determine how to accurately and reliably mark the fracture site and block side before placing the nerve block. Typically, the surgeon must mark the site before block placement when in an operative setting. In this case, it is unlikely to be marked, as the patient is in the ER and not in preoperative holding. A discussion of how to manage this must take place, and your team must have a systematic way to address this issue. In our institution, we chose to have a member of the ER nursing team present for the time-out before block placement. The site marking is done as part of the
multidisciplinary team time-out.

A continuous peripheral nerve catheter program for hospital admissions for a fractured neck of femur is patient-centered care at its most rewarding. This frail and vulnerable patient population can greatly benefit from the regional analgesia expertise anesthesiologists can provide.

References

  1. Riddell M, Ospina M, Holroyd-Leduc JM. Use of femoral nerve blocks to manage hip fracture pain among older adults in the emergency department: a systematic review. CJEM 2015;1–8. doi:10.1017/cem.2015.94.
  2. Szucs S, Rauf J, Iohom G, Shorten GD. Determination of the minimum initial intrathecal dose of isobaric 0.5% bupivacaine for the surgical repair of a proximal femoral fracture: a prospective, observational trial. Eur J Anaesthesiol 2015;32:759–763.

Stuart Grant, MD, ChB, FRCA, and Gavin Martin, MB, ChB, FRCA, are professors and Ellen Flanagan, MD, is an assistant professor, all in the department of Anesthesiology, Acute Pain and Regional Anesthesia Division, at Duke University Medical Center in Durham, NC.

Note: This article originally appeared in the ASRA News, Volume 16, Issue 3, pp. 9-11 (August 2016).


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