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