Background and importance Ultrasound-guided femoral nerve block (FNB) could be used as part of a multimodal preoperative pain management for patients with hip fracture. Evidence of the effects of its early implementation in the emergency room as an immediate alternative to intravenous morphine titration is sparse. Objective To investigate the effect of an early ultrasound-guided FNB performed by emergency physicians on preoperative opioid consumption, compared to standard pain management. Design, setting, and participants This open randomized controlled trial was conducted in the Emergency Department of a French hospital with patients with neck or trochanteric femoral fracture who had a pain score ≥7 out of 10 points at triage. Intervention Patients were randomized to receive an initial analgesia with an early ultrasound-guided FNB or with standard pain management. The continuation of pain treatment followed standardized pain control guidelines until hospital discharge in both groups. Outcome measure and analysis The primary outcome was preoperative opioid consumption truncated 48h after triage time, and converted in morphine milligram intravenous equivalents (MME). Secondary outcomes were time to pain relief, time for regaining walk, opioid consumption and occurrence of opioid and FNB adverse effects during the hospital stay. Exploratory outcomes included ease and duration of the procedure. Main results We randomized 35 patients: 17 to standard pain management and 18 to ultrasound-guided FNB, among whom 30 patients completed the protocol. The median of preoperative opioid consumption was reduced by 60% in the ultrasound-guided FNB group compared to standard group [6 MME (3–9) vs. 15 MME (11–18)], with a consumption difference of 9 MME (95% CI: 3–14, P < 0.001). Throughout hospital stay, opioid consumption was reduced by 56% in the ultrasound-guided FNB group compared to standard group, with a consumption difference of 11.5 MME (95% CI: 0.5–22).Times to pain relief and for regaining walk did not differ between groups. Opioid adverse events occurrence were reduced by 40% (95% CI: 5.1–74.9) in the ultrasound-guided FNB group compared to standard group. No adverse effects of FNB have been detected. Conclusion Early ultrasound-guided FNB resulted in reducing preoperative opioid consumption, without delaying time to pain relief.

Effect of early ultrasound-guided femoral nerve block on preoperative opioid consumption in emergency patients with hip fracture: a randomized trial

The pericapsular nerve group (PENG) block has been shown to be an effective approach to alleviating pain and reducing the need for opioids among older adults following hip surgery, with possible motor-sparing effects. No reports to date, however, have described appropriate ropivacaine volumes for use in the context of PENG block. The present prospective randomized controlled study was thus developed to assess the quadriceps muscle strength and analgesic efficacy associated with PENG block performed using three different volumes of 0.33% ropivacaine following general anesthesia in older adults undergoing hip arthroplasty.In this prospective randomized double-blind controlled clinical study, 60 patients were assigned at random to undergo ultrasound-guided PENG block for hip arthroplasty using different volumes of ropivacaine. Specifically, these patients were administered 10 ml (Group A, n = 20), 20 ml (Group B, n = 20), or 30 ml (Group C, n = 20) of 0.33% ropivacaine. Quadriceps muscle strength was evaluated at 6 h post-surgery. Visual analog scale (VAS) scores at rest and with movement were assessed at 4, 6, 12, and 24 h post-surgery. Block duration, adverse event incidence, and patient satisfaction were evaluated at 24 h post-surgery.Quadriceps motor block incidence rates at 6 h post-surgery in the 10 ml, 20 ml, and 30 ml groups were 5%, 20%, and 75%, respectively. Quadriceps muscle weakness at 6 h post-surgery was significantly more common in the 30 ml group relative to the others (p < 0.001). Patients administered 10 ml 0.33% ropivacaine exhibited significantly higher VAS pain scores at rest and with movement relative to those patients in the 20 ml and 30 ml treatment groups at all time points (p < 0.05). No apparent differences in analgesic efficacy were observed when comparing the 20 ml and 30 ml groups at 4, 6, 12, and 24 h post-surgery. No significant differences in block duration, satisfaction, or adverse event incidence were observed among groups.The preservation of motor function in the 20 ml 0.33% ropivacaine group was superior to that in the 30 ml 0.33% ropivacaine group. Relative to the group that received 10 ml 0.33% ropivacaine during PENG block, those elderly patients administered 20 ml and 30 ml volumes of 0.33% ropivacaine experienced superior postoperative pain relief following hip arthroplasty. 

Effects of Different Volumes of Ropivacaine for Pericapsular Nerve Group Block on Incidence of Quadriceps Weakness and Analgesic Efficacy Following Hip Arthroplasty: A Randomized Controlled Trial.

Abstract Background Many elder patients with hip fractures also suffered from hypertension. This study aims to explore the relationship between the use of ACEI or ARB and the outcomes of geriatric hip fractures. Methods All the patients were divided into four groups: non-users without hypertension, non-users with hypertension, ACEI users, and ARB users. The outcomes of patients in different groups were compared. LASSO regression and univariable Cox analysis were used for variable screening. Then Cox models and Logistics models were established to identify the relationships between the use of RAAS inhibitors and outcomes. Results ACER users ( p = 0.016) and ARB users ( p = 0.027) had a significantly lower survival probability than the non-users with hypertension. Non-users without hypertension, ACEI users, and ARB users may face lower 6-month and 1-year mortalities and higher 6-month and 1-year free walking rates compared with non-users with hypertension. Conclusion Patients with the use of ACEI or ARB may face a better prognosis of hip fractures. 

/pdf/the-use-of-angiotensin-converting-enzyme-inhibitors-or-16f11gv4.pdf

The use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers may relate to the survival and walking ability in geriatric patients with hip fractures: a 1-year follow-up study

Abstract Purpose Medications prescribed to older adults in US skilled nursing facilities (SNF) and administrations of pro re nata (PRN) “as needed” medications are unobservable in Medicare insurance claims. There is an ongoing deficit in our understanding of medication use during post‐acute care. Using SNF electronic health record (EHR) datasets, including medication orders and barcode medication administration records, we described patterns of PRN analgesic prescribing and administrations among SNF residents with hip fracture. Methods Eligible participants resided in SNFs owned by 11 chains, had a diagnosis of hip fracture between January 1, 2018 to August 2, 2021, and received at least one administration of an analgesic medication in the 100 days after the hip fracture. We described the scheduling of analgesics, the proportion of available PRN doses administered, and the proportion of days with at least one PRN analgesic administration. Results Among 24 038 residents, 57.3% had orders for PRN acetaminophen, 67.4% PRN opioids, 4.2% PRN non‐steroidal anti‐inflammatory drugs, and 18.6% PRN combination products. The median proportion of available PRN doses administered per drug was 3%–50% and the median proportion of days where one or more doses of an ordered PRN analgesic was administered was 25%–75%. Results differed by analgesic class and the number of administrations ordered per day. Conclusions EHRs can be leveraged to ascertain precise analgesic exposures during SNF stays. Future pharmacoepidemiology studies should consider linking SNF EHRs to insurance claims to construct a longitudinal history of medication use and healthcare utilization prior to and during episodes of SNF care. 

Use of electronic health record data to examine administrations of pro re nata analgesics during hip fracture post‐acute care

The purpose of this study is to identify the risk factors for prolonged opioid use after surgery in geriatric hip fracture patients and the effects of prolonged use on mortality and readmission rates.An institutional registry was queried for all patients older than 65 years who underwent surgical treatment of a hip fracture between January 2016 and June 2017. Using the Controlled Substance Utilization Review and Evaluation System (CURES), we identified patients who had filled an opioid prescription within 3 months of hospital admission as opioid exposed and patients without a history of opioid use as opioid naïve (ON).Of 500 patients who underwent hip-fracture surgery during the study period, a total of 322 had complete Controlled Substance Utilization Review and Evaluation System data. 36.0% (116) were OE, and 64.0% (206) were ON. 23.0% (74) patients filled an opioid prescription 6 months after surgery, 59.5% (44) were OE, and 40.5% (30) were ON. OE and patients on antidepressants were more likely to continue opioids at 6 months. Age, sex, fracture pattern, implant, benzodiazepine use, smoking, and alcohol status were not notable risk factors for prolonged opioid use. Antidepressant use was a risk factor for readmission within 90 days. Previous opioid exposure predicted mortality within 6 months.Opioid use in geriatric hip fracture patients is high both preoperatively and postoperatively. Opioid exposed patients and patients on antidepressants are more likely to continue opioids at 6 months. A substantial proportion of ON patients became prolonged opioid users. Although prolonged opioid use postoperatively did not increase the risk of readmission or death, antidepressant use predicted readmission and previous opioid exposure predicted mortality. By identifying predictors of prolonged postoperative opioid use in geriatric hip fracture patients, we can better prepare physicians and their patients on what to expect in the postoperative period.Level III. 

A Retrospective Cohort Study on Chronic Opioid Use After Geriatric Hip Fracture Surgery—Risk Factors, Trends, and Outcomes

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A Retrospective Cohort Study on Chronic Opioid Use After Geriatric Hip Fracture Surgery—Risk Factors, Trends, and Outcomes