HIP BLOCKS in
Proximal Femoral Fractures Mrs Debbie Lees Registrar T&O
Mr Mike Reed Consultant Orthopaedic Surgeon
Background • Pain relief is an important part of the hospital experience. • The British Orthopaedic Association “Standards for Trauma”1
recognise that analgesia is a key outcome. • NICE guidelines issued in June 20112 recommend the use of a local
anaesthetic block alongside systemic analgesia in the pre-operative period.
• We further recommend: – intra-operative local anaesthetic injection – indwelling catheter delivering a local anaesthetic infusion (fast track protocol)3,4 References 1. Willett K, Marsh D, Moran C, Giannoudis P, Bircher M. British Orthopaedic Association standards for trauma. J Bone Joint Surg Br 2009;91-8:985-6. 2. National Clinical Guideline Centre, June 2011. The Management of Hip Fracture in Adults. London: National Clinical Guideline Centre. Available from: www.ncgc.ac.uk 3. Kerr D, R., Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: A case study of 325 patients. Acta Orthopaedica
2008;79-2:174-83. 4. Malviya A, Reed M, press). eaAOi. Enhanced recovery programme for hip and knee replacement leads to reduction in death rate. Acta Orthopaedica In Press.
Purpose
• Audit to assess: – Procedure: (compliance, documentation, adverse reactions)
– Effect of procedure in terms of pain score
• 2 components 1. On admission – Fascia-Iliaca Block
2. Post procedure – Indwelling catheter with LA bolus
Frightened, lonely, confused, un-befriended, frail, vulnerable, abandoned……
Wide ranging side-effects… • Respiratory depression • Cough suppression • Confusion • Weakness • Trouble sleeping • Nausea • Vomiting • Loss of appetite • Tingling or redness of the skin • Blurred vision • Dependency
Demographics
N (Total) = 241
N (WGH) = 154 N (NTGH) = 87
Gender Males = 27% (WGH = 30% : NTGH = 23%)
Females = 73% (WGH – 70% : NTGH = 77%)
Mean Age 84 years (49 – 100 years)
Total Days Hospital Stay
13 days (3 -35)
Fascia-Iliaca Block
Fascia-iliac Block on Admission WGH & NTGH
Yes, 92%
No, 8%
Yes, 88%
No, 12%
Wansbeck North Tyneside
Not documented, 50%
Patient pain-free 9%
Ward transfer 9%
Equipment not available
19%
Not trained 13%
Reasons for No Block
Pre-Operative Pain Scores
Block vs No Block in NOFF Patients
Hours
Pain
Sco
re
1 2 3 4 5 6 7 8 9 10 11 12 13 14 150
2
4
6
8
10Block GroupNo Block Group
P=0.0003 CI -4.0 to -1.6
Use of Opiates Pre-Operatively
Morphine & Oramorph Requirements
Hours
Mill
igra
ms
1 2 3 4 5 6 7 8 9 100
5
10
15
Fascia-iliaca blockNo block group
P = 0.74 CI -6.7 to 5.1
Fast Track Post-operative Analgesia
Week HipQuip Update Week 14-21 Sept 2011
WGH - 7 patients recorded: • 86% Pain & Prep Compliance Rate • 100% Current Cementing Compliance Rate • 100% If Cemented - Restrictor, Catheter & Pressurised Gun Compliance Rate • 71% Fast Track Compliance Rate • 100% Post-Op checks compliance Rate • 71% Patients complying with all elements of bundle
• 1 patient missed a pre-wash and another patient was not treated as per fast track policy.
NTGH - 7 patients recorded: • 100% Pain & Prep Compliance Rate • 100% Current Cementing Compliance Rate • 100% If Cemented - Restrictor, Catheter & Pressurised Gun Compliance Rate • 71% Fast Track Compliance Rate • 100% Post-Op checks compliance Rate • 71% Patients complying with all elements of bundle
• 2 patients not treated as per fast track policy.
Full Fast Track vs LA only
Fast Track vs LA only
Observation points
Pain
Sco
re
1 2 3 4 5 6 7 8 9 10 11 12 13 14 150
1
2
3
4
Fast TrackLA only
P =0.0001 CI -0.1 to -0.48
Reasons for No Fast Track
Femoral Nerve Block, 33%
Renal Impairment, 12%
Not documented, 65%
Strengths
• >90% delivery of Fascia-Iliaca blocks • Documentation in patient notes • Pain scores are being actioned • PFF Kardex
Challenges
• Don’t forget patients on wards also need blocks/adequate analgesia
• Pre- and post- block pain score recording
• Pain scoring for demented patients
• Adequate analgesia for demented patients
Thank You