Should Regional Anesthesia Be Used for Orthopedic Trauma Patients?

Potential Benefits of Regional Anesthesia for the Orthopedic Trauma Patient

Traditional outcomes used to evaluate the effects of RA include morbidity and mortality and postoperative analgesia. Spinal and epidural anesthesia have been shown to decrease mortality and postoperative pulmonary complications in patients undergoing surgery for hip fractures. ^, RA may also provide better pain control compared with systemic opioids. Chelly and colleagues found that lumbar plexus blocks reduced morphine requirements and were associated with earlier recovery of unassisted ambulation in patients undergoing open reduction and internal fixation of acetabular fractures. Regional techniques provide site-specific analgesia and reduce opioid-induced side effects such as sedation, nausea and vomiting, itching, and respiratory depression. ^, Minimizing sedation in polytrauma patients improves the ability to monitor the mental status of patients with head injuries. ^, Difficult airway management may also be avoided through the use of RA. RA may decrease intraoperative blood loss, decrease the incidence of deep venous thrombosis (DVT), and increase range of motion for the injured extremity, which may lead to a better functional outcome. ^, Whether RA decreases the incidence of postoperative cognitive dysfunction is unclear. Some studies support this hypothesis, but others do not. Patient-centered outcomes (e.g., patient satisfaction, quality of recovery, and health-related quality of life) are also improved with the use of RA compared with general anesthesia. RA can reduce the length of stay in the postanesthesia care unit and the hospital length of stay. ^, This is especially important in patients with isolated extremity injuries who can have surgery performed as outpatients or with shortened hospital stays. Trauma patients admitted to the intensive care unit (ICU) also benefit from RA in terms of reduced pain scores, increased comfort, and decreased length of stay in the ICU. ^, The use of RA on the battlefield facilitated transport of soldiers with extensive trauma to the extremities, ^, suggesting that the use of RA as an early intervention reduces pain and injury-related complications. In addition to the short-term benefits of acute pain control, early treatment of injuries to the extremities has potential long-term benefits, including reduction in the incidence and severity of chronic pain sequelae such as complex regional pain syndrome and posttraumatic stress disorder. ^,

Despite these benefits, RA techniques have been underused in trauma patients, especially during the early phase of injury. One study reports that up to 36% of patients with acute hip fractures in the emergency department received no analgesia, and even fewer patients were considered for PNBs. ^, Another study reported that only 3% of patients with hip fractures received PNB for analgesia. RA is also underused in the perioperative period for orthopedic trauma. Side effects and the potential risk for complications after RA are often cited as reasons to avoid regional techniques. Additionally, some studies have been unable to show a significant benefit of RA in orthopedic trauma patients. Epidural analgesia was not associated with reduced opioid requirements or hospital length of stay after repair of posterior wall fracture of the acetabulum. Patients who received popliteal blocks for open reduction and fixation of ankle fractures experienced a significant increase in pain between 12 and 24 hours compared with their counterparts who received general anesthesia alone. Koval et al. followed 641 hip fracture patients and found that the anesthetic technique (general versus regional) was not associated with improvement in functional recovery at 3, 6, and 12 months after surgery. Foss and colleagues found that superior analgesia with epidural analgesia after hip fracture surgery did not translate into enhanced rehabilitation.