A Role for Local Anesthetics in Managing Hip Fracture Pain
The use of opioids to treat pain in patients who present to the emergency department with traumatic injuries such as hip fracture can be problematic, with serious concerns about opioid-related adverse effects, especially in patients with multiple comorbidities.
This concern has prompted emergency medicine and acute pain societies to encourage the use of ultrasound-guided regional anesthesia in the pre-surgical, acute care setting, such as in the emergency department, as part of a multimodal strategy for patients with a hip fracture. The goal is to reduce opioid administration as much as possible before surgery while still relieving patients’ pain.
Just how often hip fracture patients receive regional anesthesia in the acute care setting is unknown, although it is assumed that usage is increasing as more hospitals adopt multimodal, opioid-sparing pain management protocols.
Study Methods and Findings
To find out more, researchers from the Hospital for Special Surgery used the Premier Healthcare database to identify hip fracture patients who had received 1 of 4 injectable local anesthetics – bupivacaine, ropivacaine, mepivacaine, or lidocaine – on the day they presented to the emergency department.
More than 850,000 patients in the Premier database, which includes data from more than 1000 hospitals, had gone to the emergency department with a hip fracture between 2009 and 2019. The number of hip fracture patients who received injectable local anesthetics increased steadily in that decade:
- From 13.3% in 2009 to 18.6% in 2019 for bupivacaine
- From 2.0% to 9.4% for ropivacaine
- From 0.05% to 0.14% for mepivacaine
- From 28.4% to 41.0% for lidocaine
Of 864,416 patients admitted to the hospital for hip fracture between 2009 and 2019, only 1126 (0.11%) underwent surgery on the day of hospital presentation, suggesting that most of the local anesthetic use occurred before surgery, in the acute care setting.
Note: The researchers could see which anesthetic agents were ordered, but not how they were administered (nerve block, field block, or local infiltration) or who administered them (emergency medicine physicians, surgeons, anesthesiologists, or other providers). These are limitations of the study.
“Our data suggest that local anesthetic use on the day of admission is increasing, especially for long-acting local anesthetics,” said lead author Alexander Stone, MD, a regional anesthesia-acute pain medicine fellow at the Hospital for Special Surgery.
“This could be in part due to an increase in regional anesthetics being used in the emergency department, although we were not able to measure that directly using our database.”
Avoiding the Risk of Toxicity
A downside of the increased use of local anesthetics, especially long-acting anesthetics, prior to surgery is the risk of toxicity from the anesthetic agents.
“As the access to pre-surgical ultrasound guided nerve blocks increases, communication between specialties will be essential to avoid the risk of local anesthetic toxicity,” the study authors said. “Additionally, it will be important for acute pain physicians to know if their patient has previously received treatment with local anesthetics prior to preforming an ultrasound-guided nerve block.”
Dr. Stone added that he and his colleagues “are working on a follow along study, a survey made possible by ASRA Pain Medicine, to better understand who is performing nerve blocks in emergency departments and how often they are being performed by anesthesiologists.”
Dr. Stone presented the research findings during the 47th Annual Regional Anesthesiology and Acute Pain Medicine Meeting. He received 1 of 3 Resident/Fellow Travel Awards for the study. Dr. Stone was also honored with the 2022 Resident/Fellow of the Year award from the American Society of Regional Anesthesia and Pain Medicine.
Stone A, Zhong H, Poeran J, Liu J, Memtsoudis S. Injected local anesthetic use for hip fracture patients on the day of hospital presentation: a national database analysis (Abstract 2761). Presented at the 47th Annual Regional Anesthesiology and Acute Pain Medicine Meeting, March 31-April 2, 2022, in Las Vegas, Nevada.