Fractured Neck of Femur

Conference 2012

Pain Management and Anaesthesia

Dr Jane Trinca

Analgesic Aspects Of Fractured NOF:

How Have Guidelines Been Developed And Implemented? –

The Good And The Bad?

Who wrote them?

Who was on the guideline committee?

Was there appropriate representation?

How were they funded?

Volunteers or paid?

What was their purpose?

Are they specific or general?

Are they evidenced -based or expert opinion?

Have they been endorsed?

Are they reviewed?

Who has reviewed them and what was the feedback

Are they current?

Do they get updated?

Do they conflict with other guidelines?

Do other guidelines need to be used in conjunction?

Do they satisfy what you want to know in the population and environment that is relevant to you?

Are they practical ?

Have they been implemented?

Have they achieved desired result?

HOW MANY are there?

A new analgesic pathway for #NOF?

• Guidelines

• Systems

• Hard work

• Change management

• Diplomacy

Overview• Fractured NOF: Is pain an issue?

• What are factors involved around analgesia during the NOF journey

• Balancing analgesia with functional outcomes, practical considerations and adverse events.

• Does the type of anaesthesia make a difference?

• How can we prevent adverse outcomes from pain and analgesic care?

• Are guidelines the answer?

How IMPORTANT is PAIN in the NOF

journey?

Reductionist

• Pain needs to be reduced ASAP in best and most cost-effective practical manner

• Without causing harm or adverse side effects

• When fracture fixed pain should be much improved but still be present and needs to be managed so that function is optimized without causing untoward side effects

Systems approach

• Pain important determinant

function which determines

length of stay and final

outcome

• Effective analgesia decreases

time to achieve necessary

processes on NOF journey

• Errors and problems with

analgesic care have major

impact on outcome, morbidity,

mortality and costs

Pain experience after #NOF

• Pain is on movement (incident pain)– Definition of pain measurement

• Where is pain?– Pre existing pain

– Other injury beside #

– What type of pain (nociceptive/ neuropathic/ muscular) ??

• Pain severity may relate to fracture type

• How is it measured?

• Is patient cognitively impaired?

Pain matters: Effect of pain on

outcome #NOF (Morrison et al 2003)• The median age of the patients was 82 years (range 52–101),

• 83% were women, 93% were white, and 98% resided at home prior to admission and all were not cognitively impaired.

• Mean pain scores (1, no pain to 5, very severe pain) over the first 3 post-operative days were 2.5 (range 1–5) for pain at rest, 3.3 (range 1–5) for pain with transfer out of bed, and 3.7 (range 1–5) for pain with physical therapy. Fifty percent of subjects experienced moderate–severe pain at rest (score of 2.5 or higher), 83% experienced moderate to severe pain getting out of bed, and 91% experienced moderate to severe pain with physical therapy.

• Three hundred and fifty eight of 411 patients (87%) received no standing analgesia (i.e. all analgesic orders were written ‘as needed’ or ‘prn’).

• The total mean dose of parenteral morphine sulfate equivalents administered over the first 3 post-operative days was 36.7 mg (12.3 mg/day).

• PAIN 103, 303-11

Pain matters

• Post-operative pain is associated with

increased hospital length of stay, delayed

ambulation, and long-term functional

impairment (Morrison 2003)

Pain with # NOF

• 44% pre op and 42% post op severe pain (cog intact)

• Cognitively impaired received less morphine

• MOST NO STANDING ORDER FOR ANALGESIA

A Comparison of Pain and Its Treatment in

Advanced Dementia and Cognitively Intact

Patients with Hip FractureR. Sean Morrison, MD, and Albert L. Siu, MD, MSPH

Journal of Pain and Symptom Management Vol. 19 No. 4 April 2000

Poor pain control increases delirium

• Untreated pain has been shown to increase the risk of delirium in older adults undergoing elective surgery.

• Prospective cohort study at four New York hospitals of 541 patients with hip fracture and without delirium.

RESULTS:

• Eighty-seven of 541 patients (16%) became delirious.

• Risk factors for delirium were:-– cognitive impairment (relative risk, or RR, 3.6; 95% confidence interval, or CI, 1.8-7.2),

– abnormal blood pressure (RR 2.3, 95% CI 1.2-4.7),

– heart failure (RR 2.9, 95% CI 1.6-5.3).

– Patients who received less than 10 mg of parenteral morphine sulfate equivalents per day were more likely to develop delirium than patients who received more analgesia (RR 5.4, 95% CI 2.4-12.3).

– Patients who received meperidine cp to other opioids (RR 2.4, 95% CI 1.3-4.5).

– In cognitively intact patients, severe pain significantly increased the risk of delirium (RR 9.0, 95% CI 1.8-45.2).

J Gerontol A Biol Sci Med Sci. 2003 Jan;58(1):76-81.

Relationship between pain and opioid analgesics on the development of delirium following hip fracture.

Morrison RS, Magaziner J, Gilbert M, Koval KJ, McLaughlin MA, Orosz G, Strauss E, Siu AL.

Influence of analgesic technique on

delirium

• Pethidine XX

• Epidural= opioids

FIB can decrease incidence of delirium

(in low to intermediate risk)

Pain and the stress response

Consequences

• a. Hepatic glycogenolysis

• b. Insulin resistance

• c. Increased ACTH levels

• d. Reduced growth hormone levels

The sympathetic nervous system (SNS)

is stimulated by:

• Hypotension via baroreceptors

• Hypoxaemia or metabolic acidosis via

chemoreceptors

• Pain, anxiety and distress via the limbic system

and cerebral cortex

• Autonomic afferent nerves

• Hypothalamus directly activates the SNS

Detrimental effects of the stress

response• Increased myocardial oxygen demand, increasing risk of

ischaemia

• Hypoxaemia

• Splanchnic vasoconstriction which may impact on healing of anastamoses

• Exhaustion of energy supplies and loss of lean muscle mass, leading to weakness of both peripheral and respiratory muscles if severe

• Impaired wound healing and increased risk of infections

• Hypercoagulability

• Sodium and water retention

Summary of the Hormonal Stress

Response to Surgery• Increased: ACTH, cortisol,

• GH, IGF-1

• ADH, glucagon

• Reduced/ inappropriately low: Insulin

• Mobilisation of substrates Glycogenolysis

• Skeletal muscle breakdown

• Formation of acute phase proteins

• Lipolysis

Overall:

• Reduced ability to respond to and control hyperglycaemia

• Utilisation of alternative compounds, e.g. ketone bodies, as energy substrates

Anaesthetic considerations

• Dehydration

• Blood loss

• Multiple medical co-morbidites

• Multiple medications with potential

interactions

• Pain

• Multiple trauma and identification of reason

for fall?

Anaesthesia and analgesia

considerations• Pathophysiology of aging

– Cardiac ischaemia and impairment

– Cognitive impairment

– Vascular insufficicency

– Renal dysfunction

– Clotting

– Metabolism

– Deconditioning

– Frailty

– Increase GI ulceration risk

– Increased sensitivity to adverse reaction to medications and anaesthetic agents

– Difficulty performing regional anaesthesia

– Vulnerability to hypotension

– Hearing/ eyesight/ comprehension

– Depression/ anxiety/ Exhaustion

Guidelines for #NOF

• SIGN

• NICE

• Others

NICE

• Analgesia

• Assess the patient's pain:

• Immediately upon presentation at hospital and

• Within 30 minutes of administering initial analgesia and

• Hourly until settled on the ward and

• Regularly as part of routine nursing observations throughout admission

• Offer immediate analgesia to patients presenting at hospital with suspected hip fracture, including people with cognitive impairment.

• Ensure analgesia is sufficient to allow movements necessary for investigations (as indicated by the ability to tolerate passive external rotation of the leg), and for nursing care and rehabilitation.

• Offer paracetamol every 6 hours preoperatively unless contraindicated.

• Offer additional opioids if paracetamol alone does not provide sufficient preoperative pain relief.

• Consider adding nerve blocks if paracetamol and opioids do not provide sufficient preoperative pain relief, or to limit opioid dosage. Nerve blocks should be administered by trained personnel. Do not use nerve blocks as a substitute for early surgery.

• Offer paracetamol every 6 hours postoperatively unless contraindicated.

• Offer additional opioids if paracetamol alone does not provide sufficient postoperative pain relief.

• Non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended.

• Anaesthesia

• Offer patients a choice of spinal or general anaesthesia after discussing the risks and benefits.

• Consider intraoperative nerve blocks for all patients undergoing surgery.

Research recommendations NICE

(re anaesthesia) What is the clinical and cost effectiveness of regional versus general anaesthesia on

postoperative morbidity in patients with hip fracture?

Why this is important ?

No recent randomised controlled trials were identified that fully address this question. The

evidence is old and does not reflect current practice. In addition, in most of the studies the

patients are sedated before regional anaesthesia is administered, and this is not taken into

account when analysing the results. The study design for the proposed research would be

best addressed by a randomised controlled trial. This would ideally be a multi-centre trial

including 3000 participants in each arm. This is achievable given that there are about

70,000 to 75,000 hip fractures a year in the UK

The study should have three arms that look at spinal anaesthesia versus spinal anaesthesia plus sedation versus general anaesthesia; this would separate those with regional anaesthesia from those with regional anaesthesia plus sedation. The study would also need to control for surgery, especially type of fracture, prosthesis and grade of surgeon.

A qualitative research component would also be helpful to study patient preference for

type of anaesthesia.

NICE research recommendation

• The GDG recommended the following research question:

• What is the clinical and cost effectiveness of preoperative and postoperative nerve

• blocks in reducing pain and achieving mobilisation and physiotherapy goals sooner in

• patients with hip fracture?

• Why this is important

• Nerve blocks may potentially find an important role in the management of hip fracture

• pain, both pre- and postoperatively, because of their potential to reduce the requirement

• for opioids and their associated unwanted effects. Economically there are considerations

• for staff training, but also for the potential benefits in terms of duration of stay and early

• mobilisation. It is not possible from the existing literature to determine this with any

• confidence and there is a pressing need for a definitive trial comparing these outcomes

• with nerve blocks against a defined protocol of systemic opioid use.

MJA 2010 guideline (update)

• 7. Type of anaesthesia

• Regional anaesthesia is recommended for most patients, and may reduce acute postoperative confusion (A).22 For continuous spinal anaesthesia, the paramedian approach is associated with a better catheter insertion rate compared with the classic midline approach (B).23

• 8. Type of analgesia

• Adequate analgesia should be administered before and immediately after surgery. Three-in-one femoral nerve block is an effective method of providing analgesia to patients with hip fracture in the emergency department (A),24 and is useful for reducing postoperative pain (A).25Intrathecal morphine is a useful and safe technique for providing postoperative pain relief after hip fracture surgery (B).26

• Evidence-based guidelines for the management of hip fractures in older persons: an update

Jenson C S Mak, Ian D Cameron and Lyn M March, Med J Aust 2010; 192 (1): 37-41.

SIGN 2009 analgesia

Pain relief

• Pain relief should be tailored to the individual patient. Adequate and appropriate analgesia is best achieved by titration of intravenous opiates. In selected cases local nerve block may be appropriate.

• Analgesia must be administered early, in anticipation of painful procedures, such as the movement of the patient for radiological investigation. If delay occurs, repeat administration of analgesia may be required.

• adequate and appropriate pain relief should be administered before the patient is transferred from a trolley to the X-ray table.

• If necessary, pain relief should be given as quickly as possible using intravenous opiate analgesia, titrated for effect. If this is not possible (eg due to lack of appropriate supervision)

• then analgesia using entonox should be considered.

SIGN post op analgesia

• 8.1 pain relief

• There are many drugs that can be used for pain relief and many methods of administration are

• available and it is not possible in the context of this guideline to discuss specific techniques.

• The provision of good pain relief for postoperative patients is generally associated with reduced

• cardiovascular, respiratory, gastrointestinal morbidity and delirium. Good analgesia is thought

• to enhance early mobilisation and may be associated with early discharge from hospital.

• Studies have shown a reduction in postoperative opioid requirements when peripheral

• nerve blocks were used but have not shown any additional clinical benefits as a result of this

• reduction.

• 23

• The analgesic requirements of patients with fractured hip and the adequacy of current analgesic

• practice have not been fully evaluated. Adequate assessment of analgesia and pain in the

• confused older patient remains a major challenge.

• Clinical standards from NHS QIS recommend that all patients should be assessed frequently

• both at rest and during activity to ensure optimal analgesia and should receive effective acute

• pain management.

• 76

• d regular assessment and formal charting of pain scores should be adopted as routine

• practice in postoperative care.

• ; Pain management in older people should be supervised by practitioners with appropriate

• specialised experience.

SIGN 2009 anesthesia

• 6.2 general VerSuS Spinal/epidural anaeStheSia

• A systematic review found no robust evidence that spinal/epidural anaesthesia confers any benefit

• over general anaesthesia with regards to overall mortality at three, six and 12 months following

• surgical repair of hip fracture in older people (6.9% versus 10%; relative risk, RR 0.69; confidence

• interval, CI 0.5 to 0.95).

• 79

• The studies identified were of poor quality and did not reflect current

• clinical practice. There were no differences in the lengths and rates of hospital stay, pneumonia,

• stroke, cardiac failure or renal failure when comparing spinal/epidural anaesthesia with general

• anaesthesia. Spinal/epidural anaesthesia demonstrated a small but significant reduction in the

• incidence of acute confusional state postoperatively compared to general anaesthesia.

• Data on the use of anaesthesia collected by the SHFA in 2005 included 4,426 hip fracture patients

• from 13 centres. This represented 72% of hip fractures reported in Scotland that year.

• 78

• Of these

• patients around 40% received a general anaesthetic and 60% spinal/epidural anaesthesia. Although

• individual hospitals have varied their practice, this balance has remained unchanged for the last

• 10-15 years with no appreciable effect on outcomes.

• ; Spinal/epidural anaesthesia should be considered for all patients undergoing hip fracture

• repair, unless contraindicated.

SIGN peripheral nerve blocks

• 6.3 peripheral nerVe BlocKS

• A systematic review of the use of nerve block for pain relief before and/or after surgery for

• fractured neck of femur identified seven studies on the use of nerve block and one study on

• epidural analgesia. All eight studies had methodological flaws and small patient numbers.

• 23

• The

• use of peripheral nerve blocks as part of a multimodal approach to pain management following

• surgical repair of hip fracture, reduced parenteral analgesic requirement in the initial 24 hour

• following surgery. Reduction in parenteral analgesic requirements was not translated into a

• reduction in complications associated with parenteral therapy. None of the studies reported

• on mental function, functional status or return to previous residence, indicating that apart from

• reduced parenteral therapy requirement in the first 24 hours, no other clinical benefit for the

• patient was reported.

• Peripheral nerve blocks require administration by experienced personnel.

• ; The use of perioperative peripheral nerve blockade may be considered as part of the

• multimodal management of pain following surgery in hip fractures.

Guidelines Anaesthesia

• Anaesthesia 2012, 67, 85–98

• Guidelines: Management of proximal femoral fractures 2011

• Association of Anaesthetists of Great Britain and Ireland

• “Unlike existing guidelines, they review the current clinical evidence and also

• recommend best practice in numerous circumstances where evidence is

• controversial or incomplete, based on expert consensus” says consultant

• anaesthetist Dr Richard Griffiths, who chaired the working party.

• “These are the first guidelines to cover some of the difficult clinical problems

• faced by anaesthetists on a daily basis.

Anaesthesia guidelines 2011

• The ten-point action plan advises that:

• 1. There should be protocol-driven, fast-track admission of patients with hip

• fractures through the emergency department.

• 2. Patients with hip fractures require multidisciplinary care, led by

• orthogeriatricians.

• 3. Surgery is the best analgesic for hip fractures.

• 4. Surgical repair of hip fractures should occur within 48 hours of hospital

• admission.

• 5. Surgery and anaesthesia must be undertaken by appropriately

• experienced surgeons and anaesthetists.

• 6. There must be high-quality communication between clinicians and allied

• health professionals.

• 7. Early mobilisation is a key part of the management of patients with hip

• fractures.

• 8. Pre-operative management should take into consideration plans for the

• patient’s discharge from hospital.

• 9. Measures should be taken to prevent secondary falls.

• 10.Continuous audit and targeted research is required in order to inform and

• improve the management of patients with hip fracture

Meta-analysis GA vs Spinal for hip #

(2000)

Urwin BJA; 2000; 84: 450-51

GA versus Spinal 2000

Anaesthesia for #NOF Cochrane 2004

North American Review 2011

Conclusion

• Conclusion. For most interventions in this

review there were sparse data available,

which precludes firm conclusions for any

single approach or for the optimal overall pain

management following hip fracture.

FIB better than morphine for pain on

movement and opioid sparing

Epidural post op: ?

? Type of surgery

Peripheral nerve block for

anaesthesia? NORegional anaesthesia for hip fracture surgery requires blockade of:-

• the lateral cutaneous nerve of the thigh

• femoral

• obturator

• sciatic and

• lower subcostal nerves

Thus, can only be reliably achieved in the conscious patient

with neuraxial blockade

Griffiths et al. | Guidelines: proximal hip fractures Anaesthesia 2012, 67, 85–98 Anaesthesia ª 2011 The Association of

Anaesthetists of Great Britain and Ireland 91,

Peripheral nerve blocks for pain of

#NOF: YES!!

• Cochrane review 2008:

– Good evidence pts have less pain

– Inconclusive which blocks best

• Many RCTs show reduction in opioid

• Recent RCT study FIB vs opioid: FIM superior

(Kehlet group)

Analgesic pathway Austin

• Emergency– Monitoring pain

• Appropriate scale

• On function and at rest

• Response to analgesia

• Monitor side effect (sedation0

• Treat other symptoms hypotension/ nausea

– Identify • sites of pain, need for urinary catheter

• previous pain and analgesic use or previous sensitivities

• Co-morbidities

• Medications and potential for drug interactions

• Cognitive impairment (also mood, anxiety, family, language, ethnicity)

• Pre morbid mobility

Analgesic pathway

• paracetamol

• Fascia iliac compartment block (after/ before

radiology)

• Fentanyl according to pain level

• PCA or nurse controlled using PCA pump

– ? Acceptability in emergency department

• Transfer to ward (coordinate analgesic plan,

medication charts and observations)

Analgesic pathway

• All patients low level background fentanyl

intravenous infusion

• If cognitively intact PCA added

• Nurses empowered and educated to give bolus

doses of fentanyl for painful activities eg turns

and transfers

• Anaesthetists encouraged to give further FIB if

ongoing pain not particularly responsive to

opioids and further block at end of anaesthesia

Analgesic pathway

• Post operatively continue regime until patient eating and drinking then step down to oral analgesia with dose partly determined by PCA use

• Monitoring via PCA guideline and Acute Pain service

• Encourage mobilization

• If analgesia inadequate, dose is increased and pain review

• Continue paracetamol

Pain Care Plan

•Patients are started as soon as they

arrive on the ward

•Commenced on PCA

•If cognitively impaired they are on

5mcg of Fentanyl and prior to

movement nurses give a clinician

dose

•If the patient is cognitively intact

they have the PCA demand button

Outcome

• Coincides with reduction in LOS

• Ongoing audit (last 30 patients)

– Mean age 81 (44-99)

March 2011-March 2012

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Days

Average Length of Stay (HRT Data)

Exemplars

A H

Project starts

Pain Plan

Starts

% having FI blocks in emergency

block

no block

% use of peri-op IV opioid analgesia

first 48 hours

periop IV opioid

fentanyl infusion alone

PCA fentanyl alone

PCA morphine alone

fentanyl inf plus PCA

NO intravenous PCA or

infusion

Some characteristics (n=30)

IV opioid followed

by ORAL opioid

Oral prn opioid

ONLY

n with severe pain

Last 48 hours

8/30 6/23 2/7

Number requiring

extra nurse bolus

13/23

Average amount of

IV fentanyl (plus

oxycodone) in first

48 hours

600 mic(130-2622) F

45 mg oxycodone

(2.5-95mg)

N with sedation

SS= 2 or more

3 (sedn =2)

1 sedn=3 *

*one had

buprenorphine

patch found

N with delirium 7/30 5/23 *

4 had CAM 0-1

1 CAM 2 *

2/7 # one had

refused FIB and

minimal analgesia

MET for inc BP, CAM

of 2

N having spinal

anaesthetic

17/30

Fascia Iliac block

Give opioids but not too much

Give paracetamol

• Limit to 3gms per day in elderly

• Opioid sparing

• Give IV if nil orally

Be careful with NSAID

• Advantage: good analgesia and opioid sparing

• Can still cause delirium

• Bleeding possible if not COX selective

– can use COX 2

• Cause renal dysfunction if any renal

impairment

• Increased chance of GI bleed. Thus if use then

use gastric protection

Opioids

• Serious side effects: respiratory depression.

• Also constipation, nausea, depression, urinary retention, itch, delirium

• Increased sensitivity with age

• Need to monitor sedation very regularly

• Remember to check for prior opioid use (skin check for patches)

• Remember drug interactions, effects of sepsis, renal impairment

Which opioid

Consider

• Metabolites

• Renal function

• Time to act

• Ability to titrate

Opioid choice

Short acting lipid soluble

• Fentanyl

Slower acting, active metabolites

• Morphine

– SR

– IR

• Codeine

• Oxycodone

– SR

– IR

• Tramadol

Route of administration

Parenteral

• Sub cut

• IM

• IV

– Infusion

– PCA

Other

• Oral

• Intranasal

• Sublingual

• rectal

Anaesthesia #NOF Audit

• UK 2010

UK Anaesthesia audit #NOF 2010

• there was wide variation in time from admission to operation (24-108 h) and 30-day postoperative mortality (2-25%). Fifty percent of hospitals had a mean admission to operation time < 48 h. Forty-two percent of operations were delayed: 51% for organisational; 44% for medical; and 4% for 'anaesthetic' reasons.

• Regional anaesthesia was administered to 49% of patients (by hospital, range = 0-82%), 51% received general anaesthesia and

• 19% of patients received peripheral nerve blockade.

• Consultants administered 61% of anaesthetics (17-100%).

• Wide national variations in current management of patients sustaining proximal femoral fracture reflect a lack of research evidence on which to base best practice guidance. Collaborative audits such as this provide a robust method of collecting such evidence.

Danish Audit 2010

Conclusion

• RESULTS: The study demonstrated significant

variability in treatment and care of patients with

hip fractures among the regions of Denmark.

• Pain management inadequate

• Nutritional screening, ambulation characteristics,

training in activities of daily living, and

rehabilitation planning were consistently

inadequate.

• Length of stay was 7-11 days.

My personal experience with #NOF

• Disappointing in private and public sector

• Importance of making this condition a priority

• Empowering of family with expectations for standard of care

Thankyou