by Elizabeth Hofheinz, M.P.H., M.Ed.
Elderly patients with hip fractures don’t need anything else to worry about, much less the development of an opioid problem. Fortunately, new work from Cedars Sinai Medical Center in Los Angeles, California has found that by speeding up the time to give a fascial iliaca nerve block (FNB) can result in better patient outcomes.
Their work, “Time to Block: Early Regional Anesthesia Improves Pain Control in Geriatric Hip Fractures,” appears in the May 20, 2020 edition of The Journal of Bone and Joint Surgery.
Co-author John Garlich, M.D. is with the Department of Orthopaedic Surgery at Cedars Sinai and told OSN, “We began providing fascia iliaca blocks (FIB) to all hip fracture patients four years ago. However, the work on “Time-to-block” really began with the partnership we (orthopaedic surgeons) made with our regional anesthesiologists. An on-call block team was created so we could provide fascia iliaca blocks quickly to all hip fracture patients. We noticed that the sooner the patients received an FIB the better they felt. So we asked the question, ‘Does early time to block improve pain control in geriatric hip fracture patients?’”
“First, we found that the majority of opioids consumed (> 70%) were preop and pre-block. Thus, the preoperative period appears to be a critical time in which to dedicate FIB resources. Early block placement reduced preoperative opioid consumption and postoperative pain scores. We found no difference in opioid-related adverse events, which was surprising, however, we were underpowered to determine if early block placement reduced opioid-related adverse events like urinary retention and respiratory depression. Lastly, early block placement and improved pain control may reduce length of stay.”
Absolute best time to block? The jury’s still out
“This work has already changed our practice,” Dr. Garlich told OSN. “As soon as a patient is diagnosed with a hip fracture, we consult the block team and an FIB is placed as quickly as possible, with the goal of placement in the emergency room. We know from our study that early block placement reduces opioid consumption and improves pain control. However, our study was the first to broach this idea of ‘Time-to-Block’ and although we showed improved pain control with early block placement, further research is needed to identify the best time for block placement. We hope others will begin reporting on their time to block to help identify barriers to block placement, the cost-effectiveness of early blocks, and early blocks effect on postoperative delirium and opioid-related adverse events.”
In summary, says Dr. Garlich, “Geriatric hip fracture patients present in severe pain and must be transferred from emergency room gurneys to hospital beds, hospital beds to x-ray tables, and hospital beds to operating room tables. It is the preoperative period where an FI block can be most effective. The earlier the block is placed the better pain control these patients will have.”