Nirav H Amin1, Hank L Hutchinson2, Anthony G Sanzone3. 1. Department of Orthopedic Surgery, Loma Linda University, Loma Linda, CA. 2. Tallahassee Orthopedic Clinic, Tallahassee, FL. 3. San Diego Orthopaedic Trauma Fellowship Program, San Diego, CA.
Abstract
BACKGROUND: Liposomal bupivacaine (LB) has demonstrated efficacy across a range of surgical settings, including shoulder, knee, and hip surgery. However, data are limited on the use of LB as part of a multimodal pain management approach in hip fracture surgery. METHODS: On April 1, 2017, 4 orthopaedic surgeons and 3 anesthesiologists convened to discuss current practices and develop a consensus statement related to local infiltration analgesia with LB for hip fracture surgical procedures within the context of a multimodal opioid-sparing pain management approach. Separate workshops addressed intracapsular and extracapsular hip fracture surgery. RESULTS: Multimodal strategies before, during, and after hip fracture surgery are paramount to optimizing pain control and minimizing opioid requirements. LB infiltration should occur intraoperatively near the time of closing the incision. For both intracapsular and extracapsular procedures, oral or intravenous acetaminophen, a nonsteroidal anti-inflammatory drug (NSAID) of choice, and tramadol should be given preoperatively. Presurgical fascia iliaca block with bupivacaine HCl may help bridge the period before LB takes effect. After both procedures, patients should receive 1 dose of intravenous acetaminophen, an NSAID, and opioid rescue medication as needed, starting with tramadol. Postoperative NSAIDs may help minimize opioid use. Patient and provider education are integral to managing patient expectations and alleviating concerns about pain and opioid use. Standardized, validated, and appropriately timed pain assessments are also necessary to optimize postsurgical pain management. CONCLUSIONS: These consensus recommendations regarding multimodal pain management protocols incorporating local infiltration analgesia with LB for extracapsular and intracapsular hip fracture procedures serve as a basis for additional research. LEVEL OF EVIDENCE: Level V.
BACKGROUND: Liposomal bupivacaine (LB) has demonstrated efficacy across a range of surgical settings, including shoulder, knee, and hip surgery. However, data are limited on the use of LB as part of a multimodal pain management approach in hip fracture surgery. METHODS: On April 1, 2017, 4 orthopaedic surgeons and 3 anesthesiologists convened to discuss current practices and develop a consensus statement related to local infiltration analgesia with LB for hip fracture surgical procedures within the context of a multimodal opioid-sparing pain management approach. Separate workshops addressed intracapsular and extracapsular hip fracture surgery. RESULTS: Multimodal strategies before, during, and after hip fracture surgery are paramount to optimizing pain control and minimizing opioid requirements. LB infiltration should occur intraoperatively near the time of closing the incision. For both intracapsular and extracapsular procedures, oral or intravenous acetaminophen, a nonsteroidal anti-inflammatory drug (NSAID) of choice, and tramadol should be given preoperatively. Presurgical fascia iliaca block with bupivacaine HCl may help bridge the period before LB takes effect. After both procedures, patients should receive 1 dose of intravenous acetaminophen, an NSAID, and opioid rescue medication as needed, starting with tramadol. Postoperative NSAIDs may help minimize opioid use. Patient and provider education are integral to managing patient expectations and alleviating concerns about pain and opioid use. Standardized, validated, and appropriately timed pain assessments are also necessary to optimize postsurgical pain management. CONCLUSIONS: These consensus recommendations regarding multimodal pain management protocols incorporating local infiltration analgesia with LB for extracapsular and intracapsular hip fracture procedures serve as a basis for additional research. LEVEL OF EVIDENCE: Level V.