Use of Nerve Blocks for Hip Fracture Surgical Patients is Increasing Across the United States
In a new study conducted at Hospital for Special Surgery (HSS), researchers found that the use of presurgical ultrasound guided nerve blocks for emergency hospital admission due to hip fracture are increasing across the United States. This could indicate that positive strides are being made to reduce opioid use in these patients. These findings were presented at the 2022 Spring American Society of Regional Anesthesia and Pain Medicine (ASRA) Annual Meeting.1
Because patients with hip fractures have significant comorbidities, they are often at a higher risk of experiencing adverse effects from opioids. Using nerve blocks for pain relief in these patients can help to not only reduce pain, but also opioid use and confusion. Some emergency medicine and acute pain societies are attempting to increase the use of ultrasound guided regional anesthesia.
“This was the first attempt to look at how hip fracture patients are treated with local anesthetics prior to surgery. It is a descriptive study from a nationally representative database,” explained Alexander Stone, MD, regional anesthesia/acute pain medicine (RA/APM) fellow at HSS, who received one of three Resident/Fellow Travel Awards from ASRA for this study.
The researchers identified hip fracture patients in the Premiere Healthcare Database, excluding patients under 18 years of age, who had missing data on sex or on discharge date. The researchers identified the use of injectable local anesthetics from medication billing records and physician order entry on the day of admission.
This study included 864,416 patients with an emergency admission due to a hip fracture from 2009-2019 from 1,012 different hospitals. Of these patients, 1,126 (0.11%) underwent surgery on the day of hospital presentation.
From 2009-2019 the rates of local anesthetic use on the day of admission increased as follows:
- Bupivacaine (13.3% to 18.6%)
- Ropivacaine (2.0% to 8.4%)
- Mepivacaine (0.05% to 0.14%)
- Lidocaine (28.4% to 41.0%)
Limitations of the study include the inability to tell from medical reports whether the medication was administered as a nerve block, field block, or local infiltration. Additionally, investigators could not determine who administered the medication.
These results show a trend towards increased use of local anesthetics before surgery in patients with hip fracture. There was an increase in the use of sustained pain relief being started early in admissions, specifically with longer acting anesthetics such as bupivacaine and ropivacaine.
“The primary takeaway is that it appears more hip fracture patients are being treated with longer-acting local anesthetics prior to surgery. This could reflect changes in opioid sparing and multimodal analgesia practices,” Dr. Stone noted. “It is important for anesthesiologists to be aware of this, and for increased communication and collaboration between specialties to reduce the risk of local anesthetic toxicity.”
When discussing follow-up research, Dr. Stone said more detailed information about this topic is needed.
“This study is not granular, which is a limitation of using large administrative databases. To address this, we have created a survey for ASRA members to better assess how common it is for patients to receive nerve blocks in the setting of the emergency department,” Dr. Stone said.
If you are an ASRA member and would like to participate, click here to go to the survey.
1. Alexander B. Stone MD, Haoyan Zhong MPA, Jashvant Poeran MD PhD, Jiabin Liu MD PhD, Stavros G. Memtsoudis MD PhD MBA. “Injected local anesthetic use for hip fracture patients on the day of hospital presentation: a national database analysis.” Presented at: 47th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 31-April 2, 2021; Las Vegas, NV.
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 12th consecutive year), No. 4 in rheumatology by U.S. News & World Report (2021-2022), and the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2021-2022). In a survey of medical professionals in more than 20 countries by Newsweek, HSS is ranked world #1 in orthopedics for a second consecutive year (2022). Founded in 1863, the Hospital has the lowest complication and readmission rates in the nation for orthopedics, and among the lowest infection rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Innovation Institute works to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 145 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.