title: Preoperative traction in patients with hip fractures. Femoral nerve block in extracapsular femoral neck fractures. Effect of Postoperative Epidural Analgesia on Rehabilitation and Pain after Hip Fracture Surgery: A Randomized, Double-blind, Placebo-controlled Trial Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study Three-in-One Blocks with Ropivacaine: Evaluation of Sensory Onset Time and Quality of Sensory Block Out-of-hospital auricular acupressure in elder patients with hip fracture: a randomized double-blinded trial. Preoperative traction for hip fractures in the elderly: a clinical trial. A comprehensive hip fracture program reduces complication rates and mortality. [Comparison of the hemodynamic response in subarachnoid anesthesia with bupivacaine versus bupivacaine with fentanyl in traumatology surgery in elderly patients]. Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Effects of baricity of 0.5% or 0.75% levobupivacaine on the onset time of spinal anesthesia: a randomized trial Efficacy of Preoperative Skin Traction in Hip Fracture Patients: A Prospective, Randomized Study Intrathecal morphine for post-operative analgesia in patients with fractured hips. Combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia for hip fractures in the elderly. Physical therapy and mobility 2 and 6 months after hip fracture. [Analgesia after hip fracture repair in elderly patients: the effect of a continuous femoral nerve block: a prospective and randomised study]. Pain treatment in post-traumatic hip fracture in the elderly: regional block vs. systemic non-steroidal analgesics Fascia Iliaca Compartment Blockade for Acute Pain Control in Hip Fracture Patients: A Randomized, Placebo-controlled Trial Epidural infusion of bupivacaine and fentanyl reduces perioperative myocardial ischaemia in elderly patients with hip fracture – a randomized controlled trial Low‐dose bupivacaine with sufentanil prevents hypotension after spinal anesthesia for hip repair in elderly patients Low back pain after unstable extracapsular hip fractures: randomized control trial on a specific training. Ultrasonographic Guidance Improves Sensory Block and Onset Time of Three-in-One Blocks Intrathecal Clonidine for Postoperative Analgesia in Elderly Patients: The Influence of Baricity on Hemodynamic and Analgesic Effects Randomized comparison between sevoflurane anaesthesia and unilateral spinal anaesthesia in elderly patients undergoing orthopaedic surgery Preoperative traction for hip fracture: a randomized comparison between skin and skeletal traction in 78 patients. Hypotension Induced by Lateral Decubitus or Supine Spinal Anaesthesia in Elderly With Low Ejection Fraction Undergone Hip Surgery Continuous psoas compartment block for anesthesia and perioperative analgesia in patients with hip fractures. [Efficacy of obturator and femoral cutaneous nerve blocks for postoperative analgesia in hip surgery]. Spinal-induced Hypotension in Elderly Patients with Hip Fracture. A Comparison of Glucose-free Bupivacaine with Glucose-free Bupivacaine and Fentanyl Ultrasonographic Guidance Reduces the Amount of Local Anesthetic for 3‐in‐1 Blocks Non-invasive interactive neurostimulation in the post-operative recovery of patients with a trochanteric fracture of the femur. A randomised, controlled trial. Haemodynamic effects of intrathecal bupivacaine for surgical repair of hip fracture. Spinal Anesthesia Using Single Injection Small-Dose Bupivacaine Versus Continuous Catheter Injection Techniques for Surgical Repair of Hip Fracture in Elderly Patients Hemodynamic and Analgesic Effects of Clonidine Added Repetitively to Continuous Epidural and Spinal Blocks A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients. Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block Skin traction and placebo effect in the preoperative pain control of patients with collum and intertrochanteric femur fractures. Mortality after spinal and general anaesthesia for surgical fixation of hip fractures Relationship between pain and opioid analgesics on the development of delirium following hip fracture. Hip fracture in the elderly: the effect of anesthetic technique. The value of continuous blockade of the lumbar plexus as an adjunct to acetylsalicyclic acid for pain relief after surgery for femoral neck fractures. Why are we still using pre-operative skin traction for hip fractures? Comparison of the catheter‐technique psoas compartment block and the epidural block for analgesia in partial hip replacement surgery TENS relieves acute posttraumatic hip pain during emergency transport. Preoperative skin traction for fractures of the proximal femur. A randomised prospective trial. A Comparison Between Lidocaine Alone and Lidocaine With Meperidine for Continuous Spinal Anesthesia Hemodynamic Effects of Spinal Anesthesia in the Elderly: Single Dose Versus Titration Through a Catheter Intravenous but Not Perineural Clonidine Prolongs Postoperative Analgesia After Psoas Compartment Block with 0.5% Levobupivacaine for Hip Fracture Surgery [Postoperative course and endocrine stress reaction of geriatric patients with para-articular hip fractures. Prospective randomized study comparing spinal anesthesia and halothane intubation narcosis]. The impact of post-operative pain on outcomes following hip fracture Preoperative Skin Traction in Patients With Hip Fractures Is Not Useful Paralysis of the peroneal nerve following hip fracture treatment. Postoperative analgesia after triple nerve block for fractured neck of femur Minidose Bupivacaine–Fentanyl Spinal Anesthesia for Surgical Repair of Hip Fracture in the Aged Hypotension in elderly patients undergoing spinal anaesthesia for repair of fractured neck of femur. A comparison of two different spinal solutions. [Acute pain management in proximal femoral fractures: femoral nerve block (catheter technique) vs. systemic pain therapy using a clinic internal organisation model]. Perioperative myocardial ischaemia in patients undergoing surgery for fractured hip randomized to incremental spinal, single-dose spinal or general anaesthesia. Preoperative skin traction or pillow nursing in hip fractures: A prospective, randomized study in 123 patients Changes in body heat during hip fracture surgery: a comparison of spinal analgesia and general anaesthesia
abstract: A series of 80 patients with cervical , trochanteric or subtrochanteric hip fractures were r and omized to either treatment without traction , skin traction , or skeletal traction during the 1883 h between admission and operation . The institution of skin or skeletal traction was not particularly painful for the patient , but we found no indication that either was of discernible benefit . The number of analgesic medications needed was no higher in patients without traction . We conclude that traction should not be administered routinely to patients awaiting operation for hip fracture We r and omised 50 patients with extracapsular fractures of the femoral neck to receive either a bupivacaine femoral nerve block or systemic analgesia alone . A femoral nerve block was found to be an easy and effective procedure which significantly reduced perioperative analgesic requirements and postoperative morbidity Background : Hip fracture surgery usually carries a high dem and for rehabilitation and a significant risk of perioperative morbidity and mortality . Postoperative epidural analgesia may reduce morbidity and has been shown to facilitate rehabilitation in elective orthopedic procedures . No studies exist on the effect of postoperative epidural analgesia on pain and rehabilitation after hip fracture surgery . Methods : Sixty elderly patients were included in a r and omized , double-blind study comparing 4 days of continuous postoperative epidural infusion of 4 ml/h bupivacaine , 0.125 % , and 50 & mgr;g/ml morphine versus placebo . Both patient groups received balanced analgesia and intravenous nurse-controlled analgesia with morphine . All patients followed a well-defined multimodal rehabilitation program . Pain , ability to participate in four basic physical functions , and any factors restricting participation were assessed on the first 4 postoperative days during physiotherapy . Results : Epidural analgesia provided superior dynamic analgesia during all basic physical functions , and patients were significantly less restricted by pain , which was the dominating restricting factor in the placebo group . Motor blockade was not a restricting factor during epidural analgesia . Despite improved pain relief , scores for recovery of physical independence were not different between groups . Conclusion : Postoperative epidural analgesia after hip fracture surgery provides superior analgesia attenuating pain as a restricting factor during rehabilitation without motor dysfunction . However , superior analgesia did not translate into enhanced rehabilitation . Future studies with multimodal rehabilitation are required to establish whether superior analgesia can be translated into enhanced rehabilitation and reduced morbidity in hip fracture patients Background Recent studies have indicated that unmanaged pain , both acute and chronic , can affect mental status and might precipitate delirium , especially in elderly patients with hip fractures . The aim of this study was to assess the effectiveness of fascia iliaca compartment block ( FICB ) for prevention of perioperative delirium in hip surgery patients who were at intermediate or high risk for this complication . Material s and methods On admission , all included patients were divided into three groups according to low , intermediate or high risk for perioperative delirium . Eligible patients ( those classified as at intermediate or high risk for developing delirium ) were sequentially r and omly assigned to study treatment ( FICB prophylaxis or placebo ) according to a computer-generated r and omization code . The primary outcome was perioperative delirium . Diagnosis of the syndrome was defined using the Diagnostic and Statistical Manual of Mental Disorders , 4th edition ( DSM-IV ) and Confusion Assessment Method ( CAM ) criteria . Secondary outcome variables were severity of delirium and delirium duration . Results Delirium occurred in 33 ( 15.94 % ) out of 207 patients r and omized to FICB prophylaxis or the placebo group . Incidence of delirium in the FICB prophylaxis group was 10.78 % ( 11/102 ) , significantly different from the incidence ( 23.8 % , 25/105 ) in the placebo group [ relative risk 0.45 , 95 % confidence interval ( CI ) 0.23–0.87 ] . Nine of 17 patients with high risk for delirium and included in the FICB prophylaxis group developed delirium , whereas 10 of 16 high-risk patients included in the placebo group became delirious ( relative risk 0.84 , CI 0.47–1.52 ) . Two of 85 patients with intermediate risk for delirium and included in the FICB prophylaxis group developed delirium , whereas 15 of 89 intermediate-risk patients included in the placebo group became delirious ( relative risk 0.13 , CI 0.03–0.53 ) . Severity of delirium according to the highest value of the DRSR-98 during an episode with delirium in patients in the FICB prophylaxis group was on average 14.34 , versus 18.61 in the placebo group ( mean difference 4.27 , 95 % CI 1.8–5.64 , P < 0.001 ) . Mean duration of delirium in the FICB prophylaxis group was significantly shorter than in the placebo group ( FICB 5.22 days versus placebo 10.97 days , 95 % CI 3.87–7.62 , P < 0.001 ) . Conclusion No significant difference was found among high-risk patients between FICB prophylaxis and placebo groups in terms of delirium incidence . However , FICB prophylaxis significantly prevented delirium occurrence in intermediate-risk patients . Thus FICB prophylaxis could be beneficial , particularly for intermediate-risk patients The purpose of this prospect i ve , r and omized , double-blinded study was to evaluate the sensory onset time and the quality of sensory block of ropivacaine , a new long-acting local anesthetic , compared with bupivacaine , for 3-in-1 blocks . Fifty ASA physical status I – III patients undergoing hip surgery after trauma were r and omly assigned to two study groups of 25 patients each . The two study groups received a 3-in-1 block with either 20 mL of ropivacaine 0.5 % or 20 mL of bupivacaine 0.5 % . Blocks in both groups were performed using a nerve stimulator .  The sensory onset time and the quality of sensory block was assessed by pinprick test in the central sensory region of each of the three nerves and compared with the same stimulation in the contralateral leg . We used a scale from 100 % ( normal sensation ) to 0 % ( no sensory sensation ) . We did not find significant differences in sensory onset times between the ropivacaine group and the bupivacaine group ( 30 ± 11 vs 32 ± 10 min ) . The quality of sensory blocks was also comparable between the study groups ( 19 % ± 20 % vs 21 % ± 15 % ) . We conclude that the sensory onset time and quality of sensory block during 3-in-1 blocks performed with ropivacaine are comparable to those with bupivacaine . Ropivacaine is described as being less potent than bupivacaine , making this local anesthetic promising for 3-in-1 blocks because of its reportedly lower incidence of cardiovascular and central nervous system complications . Implication s Ropivacaine 0.5 % has a sensory onset time and quality of sensory block during 3-in-1 blocks similar to that of bupivacaine 0.5 % . Ropivacaine is described as being less potent than bupivacaine , making it a promising local anesthetic for 3-in-1 blocks because of its reportedly lower cardiovascular and central nervous system toxicity OBJECTIVES Auricular acupressure is known to decrease the level of anxiety in patients during ambulance transport . The purpose of this r and omized , double-blind , sham control study was to determine whether auricular acupressure can decrease not only the level of anxiety but also the level of pain in a group of elder patients with acute hip fracture . METHODS With the assistance of the Vienna Red Cross , 38 patients with acute hip fracture were enrolled into this study . Patients were r and omized into two study groups : the true intervention group and the sham control group . Subjects in the true intervention group ( n = 18 ) received bilateral auricular acupressure at three auricular acupressure points for hip pain . Patients in the sham group ( n = 20 ) received bilateral auricular acupressure at sham points . Baseline demographic information , anxiety level , pain level , blood pressure , and heart rate were obtained before the administration of the appropriate acupressure intervention . The level of anxiety , level of pain , hemodynamic profiles , and level of satisfaction were reassessed once the patients arrived at the hospital . RESULTS Patients in the true intervention groups had less pain ( F = 28 , p = 0.0001 ) and anxiety ( F = 4.3 , p = 0.018 ) and lower heart rate ( F = 18 , p = 0.0001 ) on arrival at the hospital than did patients in the sham control group . As a result , the patients in the true intervention group reported higher satisfaction in the care they received during the ride to the hospital . CONCLUSIONS The authors encourage physicians , health care providers , and emergency rescuers to learn this easy , noninvasive , and inexpensive technique for its effects in decreasing anxiety and pain during emergency transportation A consecutive series of 100 patients with femoral neck fractures were assessed by a mental test score on admission . The 67 scoring within the normal range were r and omly assigned to skin traction or no traction between admission and operation . Using pain assessment scales and records of analgesic consumption , there was found to be little difference between the two groups . The conclusion was that skin traction offered no benefits in pain control for the patient and therefore should not be used routinely OBJECTIVES To evaluate the rate of postoperative complications , length of stay , and 1-year mortality before and after introduction of a comprehensive multidisciplinary fast-track treatment and care program for hip fracture patients ( the optimized program ) . DESIGN Retrospective chart review with historical control . SETTING Orthopedic ward ( 110 beds ) at a university hospital ( 700 beds ) . PARTICIPANTS Five hundred thirty-five consecutive patients aged 40 and older ( 94%>or=60 ) hospitalized for hip fracture between January 1 , 2003 , and March 31 , 2004 . Three hundred and thirty-six patients ( 70.3 % ) were community dwellers before the fracture and 159 ( 29.7 % ) were admitted from nursing homes . INTERVENTION The fast-track treatment and care program included a switch from systemic opiates to a local femoral nerve catheter block ; an earlier assessment by the anesthesiologist ; and a more- systematic approach to nutrition , fluid and oxygen therapy , and urinary retention . RESULTS In the intervention group , the rate of any in-hospital postoperative complication was reduced from 33 % to 20 % ( odds ratio=0.61 , 95 % confidence interval=0.4 - 0.9 ; P=.002 ) . Rates of confusion ( P=.02 ) , pneumonia ( P=.03 ) , and urinary tract infection ( P<.001 ) were lower in the intervention group than in the control group , and length of stay was 15.8 days in the control group , versus 9.7 days in the intervention group ( P<.001 ) . For community dwellers , 12-month mortality was 23 % in the control group versus 12 % in the intervention group ( P=.02 ) . Overall 12-month mortality was 29 % in the control group and 23 % in the intervention group ( P=.2 ) . CONCLUSION The optimized hip fracture program reduced the rate of in-hospital postoperative complications and mortality . R and omized clinical trials are needed to confirm these results and eluci date the elements of the program that have the greatest effect on clinical outcomes and mortality OBJECTIVES To compare the intraoperative hemodynamic effects and ephedrine requirements in elderly patients undergoing orthopedic surgery under subarachnoid anesthesia with hyperbaric bupivacaine with or without fentanyl .  MATERIAL AND METHODS Sixty patients over 75 years of age and scheduled for semi-urgent surgical repair of a fractured femur were r and omized to two groups . Group F received subarachnoid surgery with 5 mg of bupivacaine and 15 micrograms of fentanyl . Group B received 7.5 mg bupivacaine . We recorded blood pressure , heart rate and oxygen saturation every 5 minutes and extension of anesthesia . Hemodynamic changes and ephedrine  required by each patient were analyzed , along with side effects . RESULTS Group F patients were more hemodynamically stable 10 and 20 minutes after infusion of the anesthetic , and more hypotensive episodes occurred in group B. Group B consumed significantly more  ephedrine  ( p < 0.05 ) , administered to 22 patients in group B and 6 in group F. The total dose of ephedrine  administered was greater in group B ( 190 mg ) than in group F ( 40 mg ) . The extension of anesthetic block was sufficient for surgery in all cases . No side effects from fentanyl administration were observed . CONCLUSION Adding fentanyl to the local anesthetic used for subarachnoid anesthesia in elderly patients is effective for maintaining greater hemodynamic stability , allowing use of a lower dose of hyperbaric bupivacaine and reducing the need for intravenous ephedrine during surgery STUDY OBJECTIVE We determine whether 3-in-1 femoral nerve block is effective as analgesia for fractured neck of femur when administered by emergency physicians . METHODS This was a prospect i ve , r and omized controlled trial with blinded assessors conducted in a district general hospital emergency department in the United Kingdom . Over a 6-month period , all patients with fractured neck of femur were considered for study . Patients were r and omly assigned to receive 3-in-1 nerve block with bupivacaine plus intravenous morphine or intravenous morphine . An accreditation package for all ED medical staff was devised to ensure competence in the technique of 3-in-1 nerve block .  Pain scores were recorded on arrival and at intervals up to 24 hours after admission .  Morphine consumption in the first 24 hours was recorded . RESULTS Ninety-four patients sustained fractured neck of femur during the study period ; 50 were studied . Of 44 not studied , 42 were confused , 1 did not consent , and 1 was overlooked . Patients receiving 3-in-1 nerve blocks recorded a faster time to reach the lowest pain score : 2.88 hours for patients with nerve block and 5.81 hours for control patients ( mean difference -2.93 h ; 95 % confidence interval [ CI ] -5.48 to -0.38 h ) . Nerve block recipients required significantly less morphine per hour than control patients ( mean of 0.49 mg/h versus 1.17 mg/h ; mean difference -0.68 mg/h ; 95 % CI -1.23 to -0.12 mg/h ) . CONCLUSION Three-in-one femoral nerve block is an effective method of providing analgesia to patients with fractured neck of femur in the ED . All grade s of medical staff were able to apply and consoli date this skill Purpose : Levobupivacaine has been extensively evaluated for spinal anesthesia . Its pharmacologic properties are similar to those of bupivacaine , but differences in density between two commercially-available preparations of plain levobupivacaine might lead to different block profiles . We examined the characteristics of spinal anesthesia using the same dose of 0.5 % and 0.75 % plain levobupivacaine . Methods : In this r and omized , controlled , double-blind clinical trial , 60 ASA I-III patients , scheduled for hip fracture surgery , were r and omly allocated to receive spinal anesthesia with 15 mg of either 0.5 % ( group Levo-0.5 ) , or 0.75 % ( group Levo-0.75 ) plain levobupivacaine .  Onset time ( primary outcome ) , sensory block height level by pinprick , motor block using a modified Bromage scale , and hemodynamic variables were recorded . Results : In group Levo-0.5 ( n=29 ) , surgical anesthesia was obtained within 15 ( 10–20 ) min , compared to 12 ( 7–21 ) min in group Levo-0.75 ( n=31 ) ( p=0.409 ) . The highest sensory block level was T11 ( T6–T12 ) in group Levo-0.5 , and T10 ( T8–T12 ) in group Levo-0.75 ( p=0.759 ) . Mean duration of anesthesia was 285 ( 224–303 ) min in group Levo-0.5 , and 318 ( 243–375 ) min in group Levo-0.75 ( p=0.117 ) . The groups were similar in regards to the number of failed blocks requiring general anesthesia , and the number of patients requiring vasopressors . Conclusions : In this population of elderly patients , spinal anesthesia with 15 mg of either 0.5 % or 0.75 % plain levobupivacaine result ed in similar onset of pharmacological actions , and outcomes . Potential differences in baricity did not appear to be clinical ly relevant in this setting .RésuméObjectif : La lévobupivacaïne en rachianesthésie a fait l’objet de nombreuses évaluations . Ses propriétés pharmacologiques sont semblables à celles de la bupivacaïne , mais les densités différentes de deux préparations de lévobupivacaïne simple disponibles sur le marché pourraient avoir pour conséquences des profils de blocs différents . Nous avons examiné les caractéristiques d’une rachianesthésie réalisée à l’aide d’une même dose de lévobupivacaïne simple à 0,5 % ou à 0,75 % .Méthode : Dans cette étude clinique r and omisée , contrôlée et en double aveugle , 60 patients ASA I-III devant subir une chirurgie pour une fracture de la hanche ont été r and omisés à recevoir une rachianesthésie avec 15 mg de lévobupivacaïne simple , soit à 0,5 % ( groupe Levo-0.5 ) , soit à 0,75 % ( groupe Levo-0.75 ) . Le délai d’installation ( résultat principal ) , le niveau du bloc sensitif mesuré à la piqûre , le bloc moteur mesuré par une échelle de Bromage modifiée et les variables hémodynamiques ont été enregistrés . Résultats : Dans le groupe Levo-0.5 ( n=29 ) , l’anesthésie chirurgicale a été réalisée en 15 ( 10–20 ) min , par rapport à 12 ( 7–21 ) min dans le groupe Levo-0.75 ( n=31 ) ( P=0,409 ) . Le niveau de bloc sensitif le plus élevé était T11 ( T6–T12 ) dans le groupe Levo-0.5 , et T10 ( T8–T12 ) dans le groupe Levo-0.75 ( P=0,759 ) . La durée moyenne de l’anesthésie était de 285 ( 224–303 ) min dans le groupe Levo-0.5 , et de 318 ( 243–375 ) min dans le groupe Levo-0.75 ( P=0,117 ) . Le nombre de blocs non réussis ayant nécessité une anesthésie générale et le nombre de patients nécessitant des vasopresseurs étaient semblables dans les deux groupes . Conclusion : La rachianesthésie réalisée avec 15 mg de lévobupivacaïne simple à 0,5 % ou 0,75 % chez une population de patients âgés provoque des réactions pharmacologiques semblables et donne des résultats similaires . Les différences possibles de baricité ne semblent pas avoir été pertinentes dans ce context Objective To compare the analgesic benefit of preoperative skin traction with the placement of a pillow under the injured extremity in patients with hip fractures . Design Prospect i ve , r and omized clinical study . Setting University-affiliated teaching institution . Patients and Participants One hundred consecutive patients with hip fractures admitted to the authors ' institution who met inclusion criteria were enrolled . Fifty-five patients had femoral neck fractures , and forty-five patients had intertrochanteric fractures . The average patient age was seventy-eight years . Intervention All patients were preoperatively r and omized into two intervention groups . One group underwent placement of five pounds of skin traction on the injured extremity , whereas the second underwent placement of a pillow under the injured extremity . Fifty patients were enrolled in each intervention group . Results With respect to immediate postintervention pain levels , patients treated with a pillow showed a trend toward better pain relief , as compared with patients treated with skin traction ; however , this was not statistically significant . On the morning after admission , patients treated with a pillow had a statistically significant greater reduction in pain ( p = 0.04 ) . These patients also requested a statistically significant lower amount of pain medication ( p < 0.01 ) . Conclusions The authors think that preoperative skin traction in patients with hip fractures does not provide significant pain relief , as compared with pillow placement under the injured extremity , and thus should not be routinely performed in this patient population for analgesia This prospect i ve , r and omised , double blind study examined the efficacy of intrathecal morphine for post-operative analgesia in Chinese patients undergoing surgery to repair fractured hips . There were a total of 40 American Society of Anesthesiologists physical status grade I to IV patients scheduled for surgery following a fractured neck of the femur . Patients were r and omised to a control group in which they received subarachnoid plain 0.5 % bupivacaine , 2.2 mL , and normal saline , 0.4 mL , giving a total volume of 2.6 mL , or to a study group in which they received plain 0.5 % bupivacaine , 2.2 mL , and preservative-free morphine , 0.2 mg , diluted with normal saline to a total volume of 2.6 mL. Patients were monitored for up to 24 hours by staff blinded to group allocation . The level of pain was assessed by a visual analogue pain score and the time of first request for analgesia was noted . The results show the median pain-free period in the control group was nine hours ( range , 2 - 24 hours ) , while it was 24 hours ( range , 16 - 24 hours ) in the morphine group , a significant difference ( P<0.05 ) . No major complications were reported . Intrathecal morphine is a useful technique for giving post-operative pain relief , especially in the elderly , in whom many other techniques can not be safely used BACKGROUND AND OBJECTIVES This prospect i ve r and omized study was design ed to determine the hemodynamic effects and quality of combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia in the elderly for repair of proximal femoral fractures . METHODS Twenty-nine elderly patients ranging in age from 68 to 97 years were r and omly assigned to 2 groups : a spinal anesthesia group with single-shot 3 mL 0.5 % plain bupivacaine , and a combined block group with 30 mL lidocaine 1.33 % with epinephrine for the posterior lumbar plexus block and 10 mL same mixture for the parasacral block and an iliac crest block with 5 mL lidocaine 1 % . RESULTS No need for general anesthesia was encountered in either group . Anesthesia was judged unsatisfactory in 1 of 15 patients in the combined block group . The initial decrease of mean arterial pressure was 38 % in the spinal group and 27 % in the block group and was not significantly different . A more prolonged hemodynamic effect was found in the spinal group , indicated by the more frequent use of ephedrine to stabilize blood pressure ( P<.05 ) . Patients over 85 years had a significantly larger decrease in blood pressure than younger patients ( P<.01 ) . CONCLUSIONS Plain bupivacaine spinal anesthesia and combined lumbar/sacral plexus block provided adequate anesthesia for repair of hip fracture in the elderly . Hypotension was induced by both the combined peripheral nerve block and plain bupivacaine spinal anesthesia in aged patients ; hypotension was found to be longer lasting after spinal anesthesia and of a larger magnitude in patients over 85 years of age OBJECTIVES To examine the relationship between early physical therapy ( PT ) , later therapy , and  mobility  2 and 6 months after hip fracture . DESIGN Prospect i ve , multisite observational study . SETTING Four hospitals in the New York City area . PARTICIPANTS Four hundred forty-three hospitalized older patients discharged after surgery for hip fracture in 1997 - 98 . MEASUREMENTS Patient demographics , fracture type , comorbidities , dementia , number of new impairments at discharge , amount of PT  between day of surgery and postoperative day ( POD ) 3 , amount of therapy  between POD4 and 8 weeks later , and prefracture , 2- , and 6-month mobility measured using the Functional Independence Measure . RESULTS More PT immediately after hip fracture surgery was associated with significantly better locomotion 2 months later . Each additional session from the day of surgery through POD3 was associated with an increase of 0.4 points ( P=.032 ) on the 14-point locomotion scale , but the positive relationship between early PT and mobility was attenuated by 6 months postfracture . There was no association between later therapy and 2- or 6-month mobility . CONCLUSION PT immediately after hip fracture surgery is beneficial . The effects of later therapy on mobility were difficult to assess because of limitations of the data . Well- design ed r and omized , controlled trials of the effect of varying schedules and amounts of therapy on functional status after hip fracture would be informative INTRODUCTION The usefulness of peripheral femoral nerve block for pain management after hip fracture has been established . This prospect i ve and r and omised study compared the analgesia effect of a continuous femoral nerve block ( CF ) versus two conventional analgesia procedures  after hip fracture . PATIENTS AND METHODS Patients . ( n=62 ) scheduled for surgery under spinal anaesthesia were prospect ively included . After surgery , analgesia ( 48 hours ) was r and omised : group FC ( femoral catheter , anterior paravascular approach , initial bolus followed by continuous infusion of ropivacaine 0.2 % ) , group P ( iv 2 g propacetamol/6 hours ) , group M ( sc morphine , 0.05 mg/kg per 4 hour ) . Intravenous morphine titration was performed , followed by subcutaneous ( sc ) morphine every 4 hours according to the VAS score . The primary end-point was the  morphine requirements . Secondary end-points were VAS score , side effects , and mortality . RESULTS Demographic data and surgical procedures were similar between groups . After morphine titration , the VAS pain score did not differ between groups . All patients in-group M received additional morphine .  Morphine mean consumption was increased in CF group : 26 mg ( 5 - 42 ) versus P : 8 mg ( 3 - 12 ) ( p=0.0001 ) or M : 19 mg ( 8 - 33 ) ( p<0.006 ) while constipation was decreased in P group vs CF . Percentage of patients requiring no morphine  was similar between P ( n=6 ; 28 % ) and CF ( n=6 ; 28 % ) and greater than M ( n=0 ; 0 % ) . Hospital discharge , cardiovascular or pulmonary complications and mortality after 6 months showed no statistical difference . CONCLUSION Continuous femoral nerve block provided limited pain relief after hip fracture did not reduced side effects and induced an expensive cost Background This prospect i ve , r and omized double-blind study , conducted over 19 months in a tertiary care ED , sought to determine if a fascia-iliaca regional anesthetic block provides better and safer pain relief than does parenteral analgesia . Aims This study also aim ed to determine the effectiveness of parenteral NSAID analgesia for acute hip fractures . Methods Patients > 65 years old presenting at an adult ED with acute hip fractures were r and omized upon presentation to the ED into two groups ( A and B ) using numbers generated by the EPI-INFO ™ ( Atlanta , GA : Centers for Disease Control and Prevention ) program . The r and omization list was kept by one of the authors who did not interact with the patients . Two groups of patients were to receive either ( A ) a fascia-iliaca block with bupivacaine and parenteral saline injection , or ( B ) the same block with saline and an IV NSAID injection . Upon admission to the study , vital signs such as blood pressure , mean blood pressure ( MAP ) , heart rate ( HR ) , respiratory rate ( RR ) and pain-intensity measurements [ using the Visual Analogue Scale ( VAS ) ] were obtained and repeated at 15 min , 2 h and at8 h. The occurrence of complications was registered . Results One hundred seventy-five patients were r and omized , and 21 were excluded from participation . The remaining 154 patients were grouped as : group A ( n = 62 ) or group B ( n = 92 ) . The mean pain level on admission to the ED for all patients , assessed with the VAS , was 8.21 ± 0.91 ( CI 95 % : 6.43–9.99 ) ; in group A the VAS was 7.6 ± 0.22 and in group B 8.5 ± 0.72 ( p = 0.411 ) . At 15-min evaluation , values were : group A 6.24 ± 0.17 and group B 2.9 ± 0.16 ( p < 0.001 ) . At the 2-h assessment , values were : group A 1.78 ± 0.11 and group B 2.3 ± 1.16 ( p = 0.764 ) . At 8 h the VAS for group A was 2.03 ± 0.12 and for group B 4.4 ± 0.91 ( p = 0.083 ) . Conclusion This study demonstrates that : ( 1 ) parenteral NSAIDs are very effective as analgesics after hip fractures in elderly patients , ( 2 ) fascia-iliaca regional blocks are nearly as effective for up to about 8 h after administration and ( 3 ) regional fascia-iliaca blocks effectively control post-hip fracture pain .  ( 4 ) Fascia iliaca regional block has a rapid onset Background : Hip fracture patients are in severe pain upon arrival at the emergency department . Pain treatment is traditionally based on systemic opioids . No study has examined the effect of fascia iliaca compartment blockade ( FICB ) in acute hip fracture pain management within a double-blind , r and omized setup . Methods : Forty-eight patients with suspected hip fracture were included immediately after arrival in the emergency department , before x-ray confirmation of their fracture . Included patients were r and omly assigned to two groups of 24 . In the FICB group , the patients received an FICB with 1.0 % mepivacaine and a placebo intramuscular injection of isotonic saline . In the morphine group , the patients received a placebo FICB with 0.9 % saline and an intramuscular injection of 0.1 mg/kg morphine . Patients received intravenous rescue morphine when necessary . Results : Maximum pain relief was superior in the FICB group both at rest ( P < 0.01 ) and on movement ( P = 0.02 ) . The median total morphine consumption was 0 mg ( interquartile range , 0–0 mg ) in the FICB group and 6 mg ( interquartile range , 5–7 mg ) in the morphine group ( P < 0.01 ) . More patients ( P = 0.05 ) were se date d in the morphine group at 180 min after block placement as compared with the FICB group . Conclusion : Pain relief was superior at all times and at all measurements in the FICB group . The study supports the use of FICB in acute management of hip fracture pain because it is an effective , easily learned procedure that also may reduce opioid side effects in this fragile , elderly group of patients Background : Perioperative myocardial ischaemia is an important risk factor for cardiac morbidity and mortality after noncardiac surgery . The impact of analgesic management on the incidence and severity of cardiac ischemia was studied in 77 elderly patients undergoing surgical treatment of traumatic hip fracture Background : Hip fracture is common in the geriatric population . Patients in this group are often at high risk for perioperative complications from concurrent diseases . Conventional spinal anesthesia can be associated with hypotension but has a better postoperative outcome compared to general anesthesia . We judged that a reduced dose of bupivacaine in combination with sufentanil could give reliable blocks with minimal hypotension AIM This study compares the efficacy of a walking recovery rehabilitation program with or without specific back exercises in patients affected by unstable extracapsular hip fractures and secondary back pain . Further , it reports data and images about analysed tomographic changes of the psoas muscle ipsilateral to fractures . METHODS A prospect i ve , r and omized , parallel treatment trial was carried out . Patients admitted for rehabilitation after fractures were evaluated for secondary back pain . If clinical ly indicated , patients were further scheduled for a computed tomography ( CT ) scan of the lumbar spine by which we evaluated cross-sectional changes in density and fibroadipose degeneration of the body of the psoas muscle . When back pain matched cross-sectional changes in psoas density , the patient was eligible for our study , enrolled and r and omly assigned to 1 of 2 study groups . Both groups were scheduled for hip rehabilitation and walking training plus a back protocol for the study group only . Pain was evaluated subjectively with a visual analog scale to calculate treatment effectiveness and Harris hip score was used to assess the outcome after surgery . RESULTS Thirty-seven patients out of about hundred were enrolled . In all cases CT scans showed age-related changes commonly seen in the lumbar spine and significant fibroadipose degeneration and altered density in the ipsilateral psoas muscles . With back exercises added to the st and ard rehabilitation protocol , all study patients recovered significantly better than control group patients ( P<0.04 ) in only 4 weeks of treatment . CONCLUSION Results show how hip fractures may cause psoas changes that can be of relevance for a more rational choice of physical exercises . Causes of back pain may be more complex than described by the textbooks and prognosis is more favourable following specific back training The use of ultrasound reduces the onset time , improves the quality of sensory block , and minimizes the risks associated with the supraclavicular approach for brachial plexus and stellate ganglion blockade . The present study was design ed to evaluate whether ultrasound also facilitates the approach for 3-in-1 blocks . Forty patients ( ASA physical status II or III ) undergoing hip surgery after trauma were r and omly assigned to two groups . In the ultrasound ( US ) group , 20 mL bupivacaine 0.5 % was administered under US guidance , whereas in the control group , the same amount and concentration of local anesthetic was administered with the assistance of a nerve stimulator ( NS ) . After US- or NS-based identification of the femoral nerve , the local anesthetic solution was administered , and the distribution of the local anesthetic solution was visualized and recorded on videotape in the US group . The quality and the onset of the sensory block was assessed by using the pinprick test in the central sensory region of each of the three nerves and compared with the same stimulation on the contralateral leg every 10 min for 60 min . The rating was performed using a scale from 100 % ( uncompromised sensibility ) to 0 % ( no sensory sensation ) . Heart rate , noninvasive blood pressure , and oxygen saturation were measured at short intervals for 60 min . The onset of sensory blockade was significantly shorter in Group US compared with Group NS ( US 16 + /- 14 min , NS 27 + /- 16 min , P < 0.05 ) . The quality of the sensory block after injection of the local anesthetic was also significantly better in Group US compared with Group NS ( US 15 % + /- 10 % of initial value , NS 27 % + /- 14 % of initial value , P < 0.05 ) . A good analgesic effect was achieved in 95 % of the patients in the US group and in 85 % of the patients in the NS group . In the US group , visualization of the cannula tip , the femoral nerve , the major vessels , and the local anesthetic spread was possible in 85 % of patients . Incidental arterial puncture ( n = 3 ) was observed only in the NS group . We conclude that an US-guided approach for 3-in-1 block reduces the onset time , improves the quality of the sensory block and minimizes the risks associated with this regional anesthetic technique . Implication s : The onset time and the quality of a regional anesthetic technique for the lower extremity is improved by ultrasonographic nerve identification compared with older techniques . ( Anesth Analg 1997;85:854 - 7 Intrathecal ( IT ) clonidine is an effective analgesic , but it also produces hemodynamic depression and sedation which are likely to be related to IT clonidine ’s cephalad spread within the cerebrospinal fluid . We hypothesized that IT clonidine ’s side effects could be reduced without compromising the duration and quality of analgesia by injecting clonidine IT in a hyperbaric solution and elevating the patient ’s trunk . We prospect ively r and omized 30 elderly patients to receive IT150μ gofeitherisobaric(ISO ) or hyperbaric ( HYPER ) clonidine for postoperative analgesia after surgical repair of traumatichip fracture . Hemodynamics , IV fluid administration , visual analog pain scores , sedation scores , and clonidine cerebrospinal fluid levels were recorded at fixed intervals . Patients in the ISO group required significantly more crystalloid fluid administration ( median , 2500 mL ; range , 1500–3000 mL ) than those in the HYPER group ( median , 1500 ; range , 500–3000 mL ) to maintain adequate arterial blood pressure ( P < 0.01 ) . Also , the decrease in heart rate was significantly more pronounced in the ISO than in the HYPER group ( P < 0.01 ) . The duration of analgesia was significantly larger in the ISO ( median , 400 min ; range , 115–400 min ) than in the HYPER ( median , 265 min ; range , 205–400 min ) group ( P < 0.05 ) . Sedation scores did not differ between groups . We conclude that increasing the baricity of IT clonidine solution in the conditions of our experiment reduces hemodynamic side effects but also analgesia from IT administered clonidine Background and objective : This prospect i ve , r and omized study was conducted to compare unilateral spinal block using small doses of hyperbaric bupivacaine and single-agent anaesthesia with sevoflurane in elderly patients undergoing hip surgery . Methods : Thirty patients ( > 65 yr ) undergoing hip fracture repair were r and omly allocated to receive unilateral spinal anaesthesia with hyperbaric bupivacaine 7.5 mg 0.5 % ( Group Spinal , n = 15 ) or volatile induction and maintenance anaesthesia with sevoflurane ( Group SEVO , n = 15 ) . General anaesthesia was induced by increasing the inspired concentration to 5 % . A laryngeal mask airway was placed without muscle relaxants , and the end-tidal concentrations of sevoflurane were adjusted to maintain cardiovascular stability . Hypotension ( decrease in systolic arterial pressure > 20 % from baseline ) , hypertension or bradycardia ( heart rate < 50 beats min−1 ) requiring treatment , and the length of stay in the postanaesthesia care unit was recorded . Cognitive functions were evaluated the previous day , and 1 and 7 days after surgery with the Mini Mental State Examination test . Results : Hypotension occurred in seven patients of Group Spinal ( 46 % ) and in 12 patients of Group SEVO ( 80 % ) ( P = 0.05 ) . Phenylephrine was required to control hypotension in three spinal patients ( 21 % ) and four SEVO patients ( 26 % ) ( n.s . ) . SEVO patients had lower heart rates than spinal patients from 15 to 60 min after anaesthesia induction ( P = 0.01 ) . Bradycardia was observed in three SEVO patients ( 22 % ) . Discharge from the postanaesthesia care unit required 15 ( range 5 - 30 ) min in Group Spinal and 55 ( 15 - 80 ) min in Group SEVO ( P = 0.0005 ) . Eight patients in Group Spinal ( 53 % ) and nine patients in Group SEVO ( 60 % ) showed cognitive decline ( Mini Mental State Examination test decreased ⩾ 2 points from baseline ) 24 h after surgery ( n.s . ) . Seven days after surgery , confusion was still present in one patient of Group Spinal ( 6 % ) and in three patients of Group SEVO ( 20 % ) ( n.s . ) . Conclusions : In elderly patients undergoing hemiarthroplasty of the hip , induction and maintenance with sevoflurane provide a rapid emergence from anaesthesia without more depression of postoperative cognitive function compared with unilateral spinal anaesthesia . This technique represents an attractive option when patient refusal , lack of adequate co-operation or concomitant anticoagulant therapy contraindicate the use of spinal anaesthesia 153 consecutive patients with displaced cervical and trochanteric hip fractures were considered for inclusion in this study . 75 were excluded because of senile confusion and the remaining 78 were r and omized to skeletal or skin traction  preoperatively . The effect on pain alleviation was evaluated with a Visual Analogue Scale ( VAS ) and by the number of doses of analgesics  administered . The processing time through the emergency department , radiographic department and to the ward , as well as time to operation , was registered . No significant difference in the VAS pain evaluation was found . There was a small significant increase in consumption of analgesics of no clinical importance in patients with skin traction , and no effect of traction type on the processing time or time to operation . Fracture type did not affect the outcome . Since half of the patients found the application of skeletal traction painful , compared to one fifth with skin traction , skeletal traction should not be routinely used to alleviate pain preoperatively in these patients Summary Objective The aim of the study was to assess the effect of low ejection fraction ( EF ) on hypotension during lateral or supine position of spinal anaesthesia in patients older than 75 years old . Methods We analyzed 41 patients who had undergone hip surgery between August 2000 and October 2001 in the Aydin SSK State Hospital retrospectively . Patients older than 75 years of age and an EF less than 50 % were selected and spinal anaesthesia was performed with hyperbaric bupivacaine 0.5 % , lateral decubitus or supine position . The patients were divided into two groups : Group I ( unilateral group , n = 23 ) and Group II ( supine group , n = 18 ) . History of hypertension , diabetes mellitus , and ASA status , preoperative value of EF and cardiac index , and intraoperative hypotension , bradycardia , ephedrine use , and maximal sensorial block levels were recorded . Results The age range of patients was between 75 and 103 . The maximal sensorial block level was evaluated due to lower or higher than thoracic sixth segment for each patient in intraoperative period . The sensorial block level higher than thoracic sixth segment were determined 2 patient in Group I and 14 patients in Group II ( p = 0.001 ) . Hypotension was observed in five patients in Group I and 10 patients in Group II ( p = 0.015 ) . In Group I , the number of ephedrine used patient was lower than Group II ( p = 0.015 ) . Conclusions Elderly patients with low EF were more likely to predispose to higher sensorial block level and hypotension was more common during spinal anaesthesia with supine position compared to lateral decubitus position BACKGROUND AND OBJECTIVES The perioperative use of continuous psoas compartment block ( CPCB ) was compared with traditional pain management for patients with fracture of the femur . The anatomy of CPCB was also tested in cadavers . METHODS Forty consecutive patients ( range , 67 - 96 years old ) were prospect ively r and omized either to group A ( given local anesthetics using a CPCB ) or group B ( given perioperative analgesia with meperidine ) . In another part of the study , CPCB was performed in 15 fresh cadavers , and dissection of the lumbar region was performed after dye injection . RESULTS Continuous psoas compartment block was performed successfully in all patients in group A and was used in the pre- ( 16 - 48 hours ) and postoperative ( 72 hours ) periods . Visual analog scale score in group A was lower than in group B in 5/7 preoperative and 9/9 postoperative 8 hourly assessment s. Differences reached statistical significance ( P < .05 ) in 3 and 5 of the assessment s , respectively . Patient satisfaction was higher in group A in the pre- ( P < .05 ) and postoperative periods ( P<.03 ) . The block failed to achieve surgical anesthesia in 85 % ( 17/20 ) of the patients , and additional anesthesia was needed . The anatomic study failed to support the existence of a defined " psoas compartment " previously described , and supported the clinical findings . Injected dye was found in the region of the origin of the sciatic nerve ( essential for the production of anesthesia for hip surgery ) in only 26 % ( 4/15 ) of cadavers . CONCLUSIONS The CPCB seems to be an appropriate technique for efficient and safe perioperative pain control . However , in our dissections , the psoas compartment was not well defined in all patients , thus , using this route for anesthesia may result in only partial success OBJECTIVES The treatment of pain after surgery to repair a hip fracture is essential for an early start of rehabilitation and for reducing morbidity and mortality . Given that patients are elderly and have multiple medical conditions , local-regional analgesia can be an effective approach . Our aim was to compare the efficacy of obturator and femoral cutaneous nerve blocks and total intravenous analgesia in terms of level of patient satisfaction , complications , start of rehabilitation , and cost . PATIENTS AND METHODS Prospect i ve study of 75 patients undergoing surgery to repair hip fractures . Patients were r and omized to receive intravenous analgesia only , blockade of both nerves , or blockade of only the obturator nerve .  In each group we recorded visual analog scale ( VAS ) pain scores , satisfaction with postoperative analgesia , time elapsed until start of rehabilitation , need for postoperative analgesics , side effects , and the cost of drugs . RESULTS Analgesia was significantly more effective in patients with nerve blocks than in those who received only intravenous analgesia ( mean [ SD ] VAS scores , 2.6 [ 1.4 ] and 5.6 [ 0.7 ] , respectively ) . Patients with nerve blocks also had a pain-free period of more than 24 hours ( P < .001 ) , needed fewer doses of supplementary analgesics or other drugs , had fewer side effects ( P < .01 ) , started rehabilitation earlier ( 32.6 [ 5.4 ] hours vs 45.7 [ 8.2 ] hours ) , generated less expenditure ( 2.6 Euros [ 1.5 Euros]/patient vs 7.0 Euros [ 0.4 Euros]/patient ) . The tested techniques had no complications . CONCLUSIONS The nerve blocks were effective , easy to perform , and safe . They afforded numerous advantages : extended period of postoperative analgesia , fast recovery , lower costs , and no complications Intraoperative hypotension is a common and potentially deleterious event in elderly patients undergoing spinal anaesthesia for repair of hip fractures . The synergism between intrathecal opioids and local anaesthetics may allow a reduction in the dose of local anaesthetic and cause less sympathetic block and hypotension , while still maintaining adequate anaesthesia . We studied 40 elderly patients having either an insertion of a dynamic hip screw or a hemi-arthroplasty and compared 9.0 mg glucose-free bupivacaine with added fentanyl 20 μg ( group BF ) with 11.0 m glucose-free bupivacaine alone ( group B ) . Hypotension was defined as a fall in systolic blood pressure to less than 75 % baseline or less than 90 mmHg . The incidence and frequency of hypotension in group BF were less than in group B. Similarly , falls in systolic , diastolic and mean blood pressures were all less in group BF than in group B. However , there were four failed blocks in group BF and one in group Background and Objectives . Recently it has been demonstrated that the use of ultrasound ( US ) improves the onset time and the quality of sensory block for 3‐in‐1 blocks compared with conventional nerve stimulator ( NS ) techniques . The present study was design ed to evaluate if US guidance for 3‐in‐1 blocks reduces the amount of local anesthetic compared to NS guidance . Methods . After institutional approval and informed consent , 60 patients undergoing hip surgery following trauma were r and omly assigned to three groups of 20 patients each . In group A , the 3‐in‐1 block was performed using US guidance with 20 mL 0.5 % bupivacaine . Group B received 20 mL 0.5 % bupivacaine , and group C received 30 mL 0.5 % bupivacaine during NS guidance .  The quality and the onset time was assessed by pinprick test in the central sensory region of each of the three targeted nerves and compared with the contralateral leg every 10 minutes for 1 hour by a blinded observer . The rating was undertaken using a scale from 100 % ( uncompromised sensibility ) to 0 % ( no sensation ) . Results . Overall success for the 3‐in‐1 block in group A was 95 % and in groups B and C 80 % . Onset time was significantly shorter in the US‐guided group compared with both NS‐guided groups ( group A 13 ± 6 minutes ; group B 27 ± 12 minutes ; and group C 26 ± 13 minutes ; P < .01 to groups B and C ) . Quality of sensory block was significantly better in group A ( 4 % ± 5 % of initial value ) compared with groups B and C ( group B 21 % ± 11 % of initial value , P < .01 to group A ; group C 22 % ± 19 % , P < .01 to group A ) . Conclusion . The amount of local anesthetic for 3‐in‐1 blocks can be reduced by using US guidance compared with the conventional NS‐guided technique We undertook a trial on 60 patients with AO 31A2 fractures of the hip who were r and omised after stabilisation of the fracture into two equal groups , one of which received post-operative treatment using a non-invasive interactive neurostimulation device and the other with a sham device . All other aspects of their rehabilitation were the same . The treatment was continued for ten days after operation . Outcome measurements included the use of a visual analogue scale for pain , the brief pain inventory and Ketorolac for post-operative control of pain , and an overall assessment of outcome by the surgeon . There were significantly better results for the patients receiving treatment by active electrical stimulation ( repeated measures analysis of variance , p < 0.001 ) . The findings of this pilot trial justify a larger study to determine if these results are more generally applicable OBJECTIVE To determine the optimal dose of bupivacaine in providing adequate surgical anaesthesia with minimal haemodynamic disturbances . METHODS Three different doses of spinal bupivacaine in combination with or without fentanyl for surgical repair of hip fracture were used . Sixty patients were r and omly divided into three groups ( A , B and C ) to receive a spinal anaesthetic of bupivacaine 10 mg , 8 mg and 6 mg respectively . In addition to bupivacaine , group B and C also received fentanyl 20 microg in spinal mixture . RESULTS Intra operative heart rate was statistically insignificant in all three groups . Statistically significant drop in systolic blood pressure was found in group A & B at different study timings while statistically significant drop in diastolic blood pressure was only found in group A. Sensory block characteristics were similar among all three groups . Motor block pattern was found marginally significant in group C with highest time to achieve desired block . All patients had satisfactory level of surgical anaesthesia . CONCLUSION This study concluded that low dose , 6 mg bupivacaine with 20 microg fentanyl provide adequate anaesthesia for surgical repair of hip fracture with stable haemodynamics Aging and disease may make elderly patients particularly susceptible to hypotension during spinal anesthesia . We compared the hemodynamic effect of continuous spinal anesthesia ( CSA ) and small dose single injection spinal anesthesia ( SA ) regarding the incidence of hypotension . Seventy-four patients aged > 75 yr undergoing surgical repair of hip fracture were r and omized into 2 groups of 37 patients each . Group CSA received a continuous spinal anesthetic with a titration of 2.5 mg boluses every 15 min of isobaric bupivacaine , while group SA received a single injection spinal anesthetic with 7.5 mg of isobaric bupivacaine . The overall variations in noninvasive automated arterial blood pressure were not statistically significantly different in the 2 groups at baseline and after CSA or SA ( not significant ) . In the SA group , 68 % of patients experienced at least one episode of hypotension ( decrease in systolic arterial blood pressure greater than 20 % of baseline value ) versus 31 % of patients in the CSA group ( P = 0.005 ) . In the SA group , 51 % of patients experienced at least one episode of severe hypotension ( decrease in systolic arterial blood pressure more than 30 % of baseline value ) versus 8 % of patients in the CSA group ( P < 0.0001 ) . In the CSA group , 4.5 ± 2 mg of ephedrine was injected versus 11 ± 2 mg in the SA group ( P = 0.005 ) . In the CSA group , 5 mg ( 2.5–10 ) of anesthetic solution was required versus 7.5 mg in the SA group ( P < 0.0001 ) . We conclude that , in elderly patients undergoing hip fracture repair  , CSA provides fewer episodes of hypotension and severe hypotension compared with a single intrathecal injection of 7.5 mg bupivacaine Clonidine in spinal and epidural blocks prolongs anesthesia , but can cause hypotension and bradycardia . The aim of our study was to compare hemodynamic and analgesic effects of spinal versus epidural clonidine alone and after repetitive dosing . In a prospect i ve , r and omized , double-blind study , we evaluated 40 patients scheduled for lower extremity orthopedic surgery under continuous spinal or epidural anesthesia with bupivacaine 0.5 % ( initial dose 5 mg and 50 mg , respectively ) . In either spinal or epidural technique one-half of patients received clonidine ( 150 micro gram ) in addition to bupivacaine . Repeat doses of the same anesthetic mixture were allowed in cases of subsequent pain . Mean arterial pressure ( MAP ) and heart rate were recorded for 6 h after each injection . Duration of clinical ly useful anesthesia was defined as the time from drug administration to first sensation of pain . Intrathecal , but not epidural , clonidine decreased MAP significantly compared with bupivacaine alone . MAP after intrathecal clonidine with bupivacaine was lower than epidural clonidine with bupivacaine 5 and 6 h after injection . Repetitive administration caused no further decrease in MAP . Onset time required to surgical anesthesia ( sensory block of T11 ) did not differ among the four groups . Duration of spinal and epidural anesthesia was increased more than two fold by clonidine . In summary , the addition of clonidine prolongs analgesia by either route . These results may be explained by clonidine 's sites of action in hemodynamic control and the density of bupivacaine-induced block . ( Anesth Analg 1995;80:322 - 7 OBJECTIVES To develop and test the effect of a nurse-led interdisciplinary intervention program for delirium on the incidence and course ( severity and duration ) of delirium , cognitive functioning , functional rehabilitation , mortality , and length of stay in older hip-fracture patients . DESIGN Longitudinal prospect i ve before/after design ( sequential design ) . SETTING The emergency room and two traumatological units of an academic medical center located in an urban area in Belgium . PARTICIPANTS 60 patients in an intervention cohort ( 81.7 % females , median age = 82 , interquartile range ( IQR ) = 13 ) and another 60 patients in a usual care/nonintervention cohort ( 80 % females , median age = 80 , IQR = 12 ) . INTERVENTION ( 1 ) Education of nursing staff , ( 2 ) systematic cognitive screening , ( 3 ) consultative services by a delirium re source nurse , a geriatric nurse specialist , or a psychogeriatrician , and ( 4 ) use of a scheduled pain protocol . MEASUREMENTS All patients were monitored for signs of delirium , as measured by the Confusion Assessment Method ( CAM ) . Severity of delirium was assessed using a variant of the CAM . Cognitive and functional status were measured by the Mini-Mental State Examination ( MMSE ) ( including subscales of memory , linguistic ability , concentration , and psychomotor executive skills ) and the Katz Index of activities of daily living ( ADLs ) , respectively . RESULTS Although there was no significant effect on the incidence of delirium ( 23.3 % in the control vs 20.0 % in the intervention cohort ; P = .82 ) , duration of delirium was shorter ( P = .03 ) and severity of delirium was less ( P = .0049 ) in the intervention cohort . Further , clinical ly higher cognitive functioning was observed for the delirious patients in the intervention cohort compared with the nonintervention cohort . Additionally , a trend toward decreased length of stay postoperatively was noted for the delirious patients in the intervention cohort . Despite these positive intervention effects , no effect on ADL rehabilitation was found . Results for risk of mortality were inconclusive . CONCLUSIONS This study demonstrated the beneficial effects of an intervention program focusing on early recognition and treatment of delirium in older hip-fracture patients and confirms the reversibility of the syndrome in view of the delirium 's duration and severity Background : In this prospect i ve r and omized study , the authors compared the analgesic effect of a fascia iliaca compartment ( FIC ) block with that of intravenous ( i.v . ) alfentanil when administered to facilitate positioning for spinal anaesthesia in elderly patients undergoing surgery for a femoral neck fracture BACKGROUND Proximal femur fractures are one of the most common injuries necessitating operative treatment . The aim of this prospect i ve study was to evaluate and compare the possible effects of the preoperative application of a skin traction device , with or without weights , on pain relief in patients with acute proximal femur fracture . MATERIAL S AND METHODS This study included 108 pre-operative patients with hip fractures . The subjects were r and omly divided into three groups , and the following treatments were administered : Group 1 , skin traction with 2 kg of weights ; Group 2 , skin traction without weights ; and Group 3 , pillow placement under the affected limb . RESULTS Pain was assessed using the visual analog scale ( VAS ) . No significant differences were observed in the scores of the three groups before the pain relief treatment . All three modes of treatment result ed in significant pain reduction in subjects . Patients treated without a weight-loaded skin traction kit had better pain relief compared to the other two groups ; this outcome was statistically significant . CONCLUSION This study indicates that pillow placement under an injured limb can be safely used instead of traction , which has no significant benefit . However , an external device , such as a skin traction kit without weight , may be used in patients with persistent pain ; this external device may have an additive placebo effect , as was proven in this study One thous and , three hundred and thirty three patients who underwent anaesthesia for surgical fixation of a hip fracture were studied prospect ively to assess the effects on outcome of general and spinal anaesthesia . There were no significant differences between the groups in risk factors , length of hospital stay or mortality rates after 30 days or one year . The data presented may be useful for those wishing to audit anaesthetic services provided to patients with hip fracture BACKGROUND Delirium and pain are common following hip fracture . Untreated pain has been shown to increase the risk of delirium in older adults undergoing elective surgery . This study was performed to examine the relationship among pain , analgesics , and other factors on delirium in hip fracture patients . METHODS We conducted a prospect i ve cohort study at four New York hospitals that enrolled 541 patients with hip fracture and without delirium . Delirium was identified prospect ively by patient interview supplemented by medical record review . Multiple logistic regression was used to identify risk factors . RESULTS Eighty-seven of 541 patients ( 16 % ) became delirious . Among all subjects , risk factors for delirium were cognitive impairment ( relative risk , or RR , 3.6 ; 95 % confidence interval , or CI , 1.8 - 7.2 ) , abnormal blood pressure ( RR 2.3 , 95 % CI 1.2 - 4.7 ) , and heart failure ( RR 2.9 , 95 % CI 1.6 - 5.3 ) . Patients who received less than 10 mg of parenteral morphine sulfate equivalents per day were more likely to develop delirium than patients who received more analgesia ( RR 5.4 , 95 % CI 2.4 - 12.3 ) . Patients who received meperidine were at increased risk of developing delirium as compared with patients who received other opioid analgesics ( RR 2.4 , 95 % CI 1.3 - 4.5 ) . In cognitively intact patients , severe pain significantly increased the risk of delirium ( RR 9.0 , 95 % CI 1.8 - 45.2 ) . CONCLUSIONS Using admission data , clinicians can identify patients at high risk for delirium following hip fracture . Avoiding opioids or using very low doses of opioids increased the risk of delirium . Cognitively intact patients with undertreated pain were nine times more likely to develop delirium than patients whose pain was adequately treated . Undertreated pain and inadequate analgesia appear to be risk factors for delirium in frail older adults Seven hundred forty-nine community-dwelling , previously ambulatory , elderly patients who sustained a femoral neck or intertrochanteric fracture underwent prospect i ve follow-up to determine whether anesthetic technique ( spinal or general ) had an effect on inpatient morbidity and mortality , or 1-year mortality .  One hundred seven patients were excluded from the study as the anesthetic technique was " predetermined " based on a underlying medical condition . Of the remaining 642 patients , 362 ( 56.4 % ) received general and 280 ( 43.6 % ) received spinal anesthesia . Twenty ( 3.1 % ) patients died during hospitalization ; 73 ( 11.4 % ) patients developed one or more postoperative medical complications . The 1-year mortality rate was 12.1 % . There was no difference in inpatient morbidity and mortality , or 1-year mortality rates between patients receiving general or spinal anesthesia In a r and omized , double-blind investigation the analgesic effect of continuous blockade of the lumbar plexus as an adjunct to acetylsalicyclic acid by suppository  after surgery for femoral neck fractures under spinal anaesthesia was examined in 20 patients . Before surgery , a catheter was inserted into the femoral nerve sheath . The patients were allocated r and omly to receive bupivacaine or saline by bolus and then continuous infusion , started immediately after the operation . No statistically significant differences in additional morphine requirements , visual analogue pain scores or adverse effects were observed between the two treatment groups . It is concluded that continuous blockade of the lumbar plexus as an adjunct to rectal acetylsalicyclic acid offers no major additional pain relief after surgery for femoral neck fractures under spinal anaesthesia Abstract . We performed a prospect i ve r and omised trial to evaluate the efficacy of  pre-operative skin traction  for proximal femoral fractures in 311 patients . We found a significant difference in pain score on the evening of admission and the first morning after admission between the groups with traction compared the group without . However , there was no corresponding increase in analgesic requirement during this period . The peak pain score pattern also was different in our population . No other objective benefit can be shown from using skin traction , and its routine use should be ab and oned . Résumé . Nous avons mené une étude prospect i ve et r and omisée pour évaluer l'efficacité de la traction cutanée préopératoire pour les fractures fémorales proximales chez 311 malades . Nous avons trouvé une différence notable dans le score de la douleur le soir de l'admission et le premier matin après l'admission entre le groupe avec traction comparé au groupe sans traction . Cependant , il n'y avait pas d'augmentation correspondante de la nécessité d'analgésiques pendant cette période ou la douleur était cotée au plus haut . Aucun autre avantage objectif d'utiliser la traction cutanée n'a été montré et son usage habituel devrait être ab and onné Background : The aim of this study was to compare the intra‐ and postoperative analgesia provided by the catheter‐technique psoas compartment block and the epidural block in hip‐fractured patients . We also compared hemodynamic stability , motor blockade , ease of performing the technique , and complications BACKGROUND In Central Europe , ambulances for patients suffering from pain caused by nonlife-threatening trauma , such as hip fractures are staffed by medical personnel ( medics ) without physicians . Thus , there is an urgent need for nonpharmacological interventions that can be applied during the transport by basic life-support ( BLS ) medical personnel . METHODS In all , 101 patients were screened for participation in this r and omized placebo-controlled double-blind study , and r and omly assigned to two groups ( verum and sham transcutaneous electrical nerve stimulation [ TENS ] ) . First , medic A recorded all baseline parameters and measurements , then medic B performed TENS in absence of medic A. At the end of transportation , medic A performed data collection . Each patient was asked to grade his/her pain and anxiety level on visual analog scales ( VAS , 0 to 100 mm ) . RESULTS From 101 screened patients fulfilling the entry criteria , 29 declined consent and 9 had to be excluded from the analysis because of their final diagnosis . Therefore , the data from 30 patients ( group 1 , verum TENS ) as well as from 33 patients ( group 2 [ control ] , sham TENS ) were analyzed . No significant differences in potentially influencing factors were found before treatment . Pain scores upon arrival at the hospital differed significantly between group 1 and group 2 ( p < 0.01 ) . In group 1 , pain reduction was observed between departure from the site of emergency and arrival at the hospital ( VAS : 89 + /- 9 to 59 + /- 6 mm ) , whereas pain scores remained nearly unchanged in group 2 ( VAS : 86 + /- 12 to 79 + /- 11 mm ) . CONCLUSION Our findings show that TENS is a valuable and fast-acting pain treatment under the difficult circumstances of " out-of-hospital rescue " . Because of its lack of side effects , it could also be a valuable tool in the hospital We report the results of a r and omised trial to determine the effects of skin traction on 252 patients awaiting surgery for fractures of the proximal femur . They were allocated r and omly to be nursed free in bed or to receive Hamilton-Russell skin traction . No differences were found between the groups in terms of pain suffered , analgesia required , frequency of pressure sores or ease of operation . The application of skin traction to patients with fractures of the upper femur is time-consuming and we recommend therefore that its routine use should be discontinued Background and Objectives . Experimental investigations have demonstrated a synergistic interaction between opioids and local anesthetics . This study aims to assess the effective benefit-risk ratio of continuous spinal anesthesia ( CSA ) induced with either 1.6 % lidocaine alone or in combination with 1 % meperidine . Methods . Thirty-four elderly patients ( 80.7 ± 7.3 years ) operated on for fracture of the neck of the femur were r and omly allocated to two groups . In the first group ( n = 15 ) , CSA was induced with lidocaine 1.6 % plain , whereas in the second group ( n = 19 ) 1 % meperidine was added . Reinjections were performed in both groups using lidocaine 1.6 % alone . Results . In the lidocaine group , 43 ± 13 mg was used for induction whereas in the other group the addition of 18 ± 5 mg of meperidine significantly reduced the dose of lidocaine required to 28 ± 8 mg ( p < 0.001 ) . Delay between two reinjections was increased to 51 ± 7 minutes in the lidocaine plus meperidine group , compared to 35 ± 6 minutes in the lidocaine group ( p < 0.001 ) . Ephedrine  was required for 9 out of the 19 patients in the lidocaine plus meperidine group , whereas it was required for only two patients in the other group ( p = 0.05 ) . Mean plasma concentrations of meperidine 1 hour and 3 hours after induction was 45.5 ± 12 ng/ml and 59 ± 22 ng/ml , respectively , and drowsiness was observed in 95 % of the patients in the second group . Delay before requirement for pain medication was 2.2 ± 2 hours in the lidocaine group and 14.1 ± 8 hours in the lidocaine plus meperidine group ( p < 0.001 ) . Conclusions . The association of 1 % meperidine with 1.6 % lidocaine during the induction of CSA decreases the initial induction dose , prolongs analgesia , produces initial drowsiness , and provides long-lasting pain relief . However , such benefits are offset by some impairment of hemodynamic stability that is likely to make this combination of drugs unacceptable as an enhanced analgesic technique Sixty elderly patients ( > 70 yr old ) undergoing surgery for hip fracture were prospect ively studied in order to compare hemodynamic tolerance of titrated doses of hyperbaric bupivacaine using continuous spinal anesthesia ( CSA ) versus single-dose spinal anesthesia ( SDSA ) . Patients were r and omized into two groups ( CSA group : n = 30 ; SDSA group : n = 30 ) . The SDSA patients received 10 - 15 mg of 0.5 % hyperbaric bupivacaine ( based on age and height ) , and the CSA patients received a starting dose of 5 mg of 0.5 % hyperbaric bupivacaine , followed after 15 min by optional reinjection of 2.5 mg every 5 min until a T10 level sensory block was reached . Onset of anesthesia , noninvasive hemodynamic variables and the need for ephedrine  were studied for 4 h after induction of anesthesia . Spinal anesthesia was successful in all patients . Decreases in mean arterial pressure were significantly less frequent and less pronounced in the CSA group ( 19.9 % + /- 1.6 % of the baseline value ) than in the SDSA group ( 40.2 % + /- 1.9 % , P < 0.0001 ) . The mean dose of ephedrine  was significantly less in the CSA group ( 1.8 + /- 0.7 mg , administered to only 37 % of patients ) than in the SDSA group ( 19.4 + /- 3.3 mg administered to all patients , P < 0.0001 ) . No late complications related to the spinal anesthesia technique were observed in either group . We concluded that CSA , using small titrated doses of 0.5 % hyperbaric bupivacaine , is safe , efficient , and provides better hemodynamic stability than SDSA in elderly patients . ( Anesth Analg 1996;82:312 - 6 We evaluated the systemic and local effects of clonidine as an analgesic adjunct to psoas compartment block ( PCB ) with levobupivacaine . In a r and omized , prospect i ve , double-blind trial , 36 patients requiring hip fracture surgery received PCB and general anesthesia .  Patients were r and omized into three groups . Each patient received PCB with 0.4 mL/kg of levobupivacaine 0.5 % . The control group ( group L ) received IV saline , the systemic clonidine group ( group IC ) received IV clonidine 1 & mgr;g/kg , and the peripheral clonidine group ( group C ) received IV saline and PCB with clonidine 1 & mgr;g/kg . The interval from time of completion of block injection to first supplementary analgesic administration was longer in group IC compared with group L ( mean ± sd , 13.4 ± 6.1 versus 7.3 ± 3.6 h ; P = 0.03 ) . There was no difference between group C and group L ( 10.3 ± 5.9 versus 7.3 ± 3.6 h ; P > 0.05 ) . The groups were similar in terms of 24 h cumulative morphine and acetaminophen consumption . There were no significant differences among groups regarding postoperative adverse effects ( bradycardia , hypotension , sedation , and nausea ) . We conclude that IV but not perineural clonidine ( 1 & mgr;g/kg ) prolongs analgesia after PCB without increasing the incidence of adverse effects During a period of one year , all patients above the age of 60 with surgical repair of fractured neck of femur were investigated in a prospect ively r and omized design . A follow-up study included a total number of 56 patients , 32 were allocated to halothane anaesthesia with intubation , 24 received spinal anaesthesia .  In addition , 15 patients of the halothane group and 17 patients with spinal anaesthesia  were investigated with regard to endocrine stress response . Total mortality was 12.5 % , and different anaesthetic management had no influence on the postoperative course . During the operation , adrenaline and ADH increased in both groups . This increase was attenuated by spinal anaesthesia .  Noradrenaline was markedly increased even before the operation , and concentrations increased in the halothane group in the course of the operation . There was a linear correlation to time between accident and the beginning of the operation . With regard to endocrine parameters , prompt surgical treatment is beneficial & NA ; Untreated pain is a major health care issue and very little is known about the treatment of pain and the effect of pain on post‐operative outcomes in older adults . This study was performed to identify the impact of pain on outcomes following hip fracture in older adults . Four hundred and eleven consecutive cognitively intact patients admitted with hip fracture to four New York hospitals were enrolled in a prospect i ve cohort study . Patients were interviewed daily using st and ardized pain assessment s. We used multiple logistic regression and ordinary least squares linear regression to examine the association of post‐operative pain on immediate post‐operative outcomes ( duration of stay , physical therapy sessions missed or shortened , ambulation following surgery , and post‐operative complications ) and outcomes 6 months following fracture ( locomotion , mortality , return to the community , residual pain ) . Patients with higher pain scores at rest had significantly longer hospital lengths of stay ( P=0.03 ) , were significantly more likely to have physical therapy sessions missed or shortened ( P=0.002 ) , were significantly less likely to be ambulating by post‐operative day 3 ( P<0.001 ) , took significantly longer to ambulate past a bedside chair ( P=0.01 ) , and had significantly lower locomotion scores at 6 months ( P=0.02 ) . Pain at rest was not significantly associated with post‐operative complications , nursing home placement , survival at 6 months , or residual pain at 6 months . Post‐operative pain is associated with increased hospital length of stay , delayed ambulation , and long‐term functional impairment . Whereas appropriate caution is warranted in administering opioid analgesics to older adults , these data suggest that improved pain control may decrease length of stay , enhance functional recovery , and improve long‐term functional outcomes One hundred twenty patients with cervical or trochanteric hip fractures were allocated r and omly to groups receiving either skin traction or no special treatment while awaiting surgery .  No differences were found between the groups in terms of pain experienced , the need for supplementary analgesics , or complications during the hospital stay . In addition , the repositioning and percentage of united fractures after 4 months did not differ significantly between the groups . The application of skin traction offered no benefits , and thus routine use of preoperative skin traction in patients with hip fractures is not recommended A prospect i ve study was performed over a period of 2 years to identify the cause of peroneal palsy following hip fracture treatment . Sixty-eight patients in Group I had their injured leg  placed in traction in a splint with a metal frame . In Group II ( 66 patients ) elevation only of the fractured extremity was maintained with a few pillows . There were five cases of peroneal palsy in Group I and none in Group II . The difference is significant . Direct pressure on the nerve in the area of the fibular head during the preoperative traction period seems to be the cause of this transient dysfunction Fifty patients with fractured neck of femur that required surgical correction with either a compression screw or pin and plate device were r and omly allocated to receive one of two anaesthetic techniques , general anaesthesia combined with either opioid supplementation or triple nerve block ( three in one block ) with subcostal nerve block . The nerve blocks significantly reduced the quantity of opioid administered after operation ; 48 % of these patients required no additional analgesia in the first 24 hours . Plasma prilocaine levels in these patients were well below the toxic threshold , and peak absorption occurred 20 minutes after the injection . No untoward sequelae were associated with the nerve blocks Background Spinal anesthesia for surgical repair of hip fracture in the elderly is associated with a high incidence of hypotension . The synergism between intrathecal opioids and local anesthetics may make it possible to achieve reliable spinal anesthesia with minimal hypotension using a minidose of local anesthetic . Methods Twenty patients aged ≥ 70 yr undergoing surgical repair of hip fracture were r and omized into two groups of 10 patients each . Group A received a spinal anesthetic of bupivacaine 4 mg plus fentanyl 20 & mgr;g , and group B received 10 mg bupivacaine . Hypotension was defined as a systolic pressure of < 90 mmHg or a 25 % decrease in mean arterial pressure from baseline . Hypotension was treated with intravenous ephedrine boluses 5–10 mg up to a maximum 50 mg , and thereafter by phenylephrine boluses of 100–200 & mgr;g . Results All patients had satisfactory anesthesia . One of 10 patients in group A required ephedrine , a single dose of 5 mg . Nine of 10 patients in group B required vasopressor support of blood pressure . Group B patients required an average of 35 mg ephedrine , and two patients required phenylephrine . The lowest recorded systolic , diastolic , and mean blood pressures as fractions of the baseline pressures were , respectively , 81 % , 84 % , and 85%versus 64 % , 69 % , and 64 % for group A versus group B. Conclusions A “ minidose ” of 4 mg bupivacaine in combination with 20 & mgr;g fentanyl provides spinal anesthesia for surgical repair of hip fracture in the elderly . The minidose combination caused dramatically less hypotension than 10 mg bupivacaine and nearly eliminated the need for vasopressor support of blood pressure Intraoperative hypotension is a common and sometimes deleterious event in elderly patients undergoing spinal anaesthesia for repair of hip fractures . The synergism between intrathecal opioids and local anaesthetics may allow a reduction in the dose of local anaesthetic and reduce hypotension , while still maintaining adequate anaesthesia . We studied 42 elderly patients having insertion of a Richards pin and plate and compared 7.5 mg hyperbanic bupivacaine with added fentanyl 20 microg ( group BF ) to 12.5 mg hyperbaric bupivacaine alone ( group B ) . Hypotension was defined as a fall in systolic blood pressure to less than 75 % baseline or less than 90 mmHg and occurred with an overall incidence of 59.5 % . There was no difference in the incidence or severity of hypotension between the two groups . Two patients from group B and one from group BF experienced mild discomfort . Pruritus was more common in group BF BACKGROUND The aim of this study was to compare safety and efficacy of catheter-mediated femoral nerve block analgesia with systemic pain therapy in patients with proximal femoral fractures in the pre-operative and post-operative setting using a protocol for coordinating pain management . METHODS In a prospect i ve r and omised trial of patients attending the emergency department , 100 individuals were selected with a clinical ly diagnosed proximal femoral fracture . Patients were divided into two equal groups A and B. Group A ( n=50 ) received a catheter-mediated femoral nerve block with 1 % prilocaine ( 40 ml ) and post-operatively 0.2 % ropivacaine ( 30 ml ) 6 hourly . Group B ( n=50 ) initially received intravenous metamizol ( 1 g ) and a fixed combination of oral tilidine ( 100 mg ) + naloxone ( 8 mg ) . Patients aged 90 years or more received a reduced dose ( tilidine 75 mg + naloxone 6 mg ) . In the post-operative period regular oral ibuprofen ( 400 mg , 8 hourly ) in addition to oral tilidine ( 50 mg ) + naloxone ( 4 mg ) was given as required for break through pain . Pain intensity was measured using a verbal rating scale ( VRS ) from 1 to 5 : pain free ( = 1 ) , mild pain ( = 2 ) , moderate pain ( =3 ) , severe pain ( = 4 ) , excruciating pain ( = 5 ) . Pain scores were recorded at rest ( R ) , during passive anteflection ( 30 degrees ) of the hip ( PA ) on arrival and at 15 and 30 min after initial administration of analgesia . Thereafter , recordings were made 4 times a day up to the third post-operative day . RESULTS Pain scores were comparable for both groups on admission ( VRS in R 2.50 vs. 2.46 ; VRS during PA 4.30 vs. 4.34 ) . Significant pain relief was achieved in both groups following initial administration of analgesia , but the total pain scores in group A were significantly lower than in group B ( VRS in R 1.22 vs. 1.58 , p<0.01 and VRS during PA 2.66 vs. 3.26 ; p<0.001 ) . No difference was noted between the two groups during the first 3 post-operative days . No severe complications occurred as a result of analgesia , however , the catheter was dislodged in 20 % of patients in group A result ing in the need for systemically administered analgesia . CONCLUSION All patients presenting with proximal femoral fractures should receive adequate analgesia within the emergency department even prior to radiographic imaging . Femoral nerve block should be considered as the method of choice . The insertion of a femoral nerve block catheter has the dual advantage of early analgesia permitting repeated clinical examination in addition to continued post-operative pain management . The cumbersome logistics inherent in this technique within the clinical setting limits its practical application . An initial single-shot regional nerve block followed by a systemic post-operative analgesia protocol was considered an appropriate alternative . The execution of safe , consistent and appropriate regional nerve block anaesthesia is reliant on formal guidelines and protocol s as agreed by the multidisciplinary teams involved with patient-directed pain management and good clinical practice Quantitative assessment of myocardial ischaemia during incremental spinal , single-dose spinal and general anaesthesia may provide guidelines for the choice of anaesthetic technique for osteo synthesis of hip fractures in the elderly atherosclerotic individual . Forty-three patients with coronary artery disease were allocated to receive either incremental spinal anaesthesia ( bupivacaine 0.5 % plain ) ( A ) , single-dose spinal anaesthesia ( 2.5 mL of bupivacaine 0.5 % plain ) ( B ) or general anaesthesia ( fentanyl , thiopentone , atracurium , enflurane , N2O/O2 ) ( C ) for hip surgery .  ST segment monitoring was performed from the induction of anaesthesia and for the following 48 h , and perioperative hypotension , blood loss and fluid therapy were recorded . ST depression developed in two out of 14 ( A ) , seven out of 15 ( B ) and six out of 14 ( C ) patients ( P = 0.14 ) . In ( A ) , a total of seven ST depressions occurred in the observation period as opposed to 125 in ( B ) and 16 in ( C ) ( P < 0.05 ) . Intra-operative ST depression only occurred in ( B ) . Three ( A ) , 33 ( B ) and 40 ( C ) hypotensive events were recorded ( P < 0.002 ) . Altogether , 56 % of hypotensive patients developed ST depression compared with 10 % of normotensive patients ( P < 0.003 ) . In ( A ) , 1.6 mL of 0.5 % bupivacaine were used as opposed to the fixed 2.5 mL dose in ( B ) ( P < 0.001 ) . In the first post-operative week , mortality was higher in ( B ) ( P < 0.05 ) but , after 1 month , there was no significant difference in mortality between the three groups . The incidence of hypotension and myocardial ischaemia was lowest in the group receiving incremental spinal anaesthesia Purpose : To study the influence on pain and h and ling of different preoperative immobilization procedures for hip fractures . Method : 123 consecutive patients with displaced cervical and trochanteric hip fractures were r and omized to skin traction , placement in a special foam pillow ( Lasse pillow ) , and comfortable placement with an ordinary pillow under the hip from admission to operation . The effect on pain alleviation was evaluated with a Visual Analogue Scale and by the number of doses of analgesics administered . The processing time through the emergency department , X-ray department and to the ward as well as time to operation was registered . Results : No clinical ly significant difference in the VAS pain evaluation was found . There was no difference in the total consumption of analgesics in the emergency department or on the ward and no effect of immobilization type on the processing time or time to operation . Fracture type did not affect the outcome . Approximately one third of the patients found placement on a regular pillow or the application of skin traction uncomfortable as opposed to only one of 19 of the patients lying in the special Lasse pillow . There was no other difference in processing time with regard to different forms of pillow nursing and skin traction . Conclusion : The most convenient immobilization should be chosen as there is no significant difference concerning pain and h and ling time . Increased attention to analgesic medication and rapid h and ling to be operated are of importance to promote the rehabilitation process Postoperative hypothermia initiates an increased oxygen dem and in the postoperative period and may endanger patients with restricted cardiopulmonary reserves . In order to compare net heat losses and gains , we studied 28 women undergoing hip fracture surgery , using either general anaesthesia or spinal analgesia .  The superficial and central temperatures were followed in the per‐ and postoperative period . Total body heat was calculated from temperature measurements . Temperature changes were unrelated to the type of anaesthesia . Large net heat losses occurred on transfer to the recovery room
target: Overall , moderate evidence suggests that nerve blockades are effective for relieving acute pain and reducing delirium .
  Low-level evidence suggests that preoperative traction does not reduce acute pain .
  Nerve blockade seems to be effective in reducing acute pain after hip fracture .
  Sparse data preclude firm conclusions about the relative benefits or harms of many other pain management interventions for patients with hip fracture .
background: BACKGROUND  Pain management  is integral to the management of hip fracture .
  PURPOSE To review the benefits and harms of pharmacologic and nonpharmacologic interventions for managing pain  after hip fracture .