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.

Reference

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.