American Society of Regional Anesthesia and Pain Medicine August 2016 - 9
Preoperative Continuous Peripheral Nerve Blocks in Hip
Fracture Patients
* 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.
Stuart Grant, MB, ChB, FRCA
Professor
W
hen 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 al1 examined
the use of femoral nerve blocks
in the ER. Both single-shot
and catheter techniques have
shown benefit by reducing pain
scores and opioid consumption.
Additionally, reductions in respiratory and cardiac side effects have
been noted without any increase in any adverse events.
Gavin Martin, MB, ChB, FRCA
Professor
Ellen Flanagan, MD
Assistant Professor
Department of Anesthesiology
Acute Pain and Regional Anesthesia Division
Duke University Medical Center
Durham, NC
Section Editor: Melanie Donnelly, MD
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, 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.
"When developing a plan to care for
elderly patients with hip fractures,
amassing a multidisciplinary team is
the first step."
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
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
American Society of Regional Anesthesia and Pain Medicine
2016
93
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