Smärta och smärtbehandling med femoralisblockad : effekter och erfarenheter: äldre patienter och personalens perspektiv

Background: Older people with hip fractures are often frail with several comorbidities and roughly half of them have dementia disorders. Pain is common among patients with hip fracture and pain management in these patients is a challenge. Opioids are known to relieve pain while at rest but are not as effective in movement. One alternative to opioids is a femoral nerve block (FNB). Previous studies have shown that FNBs can decrease pain and the need for opioids, but these studies excluded patients with dementia. Few studies have investigated whether FNBs decrease the incidence of complications in general, and delirium in particular. These studies were also based on different types of nerve blocks and methods. Few studies have described patients’ experiences of pain and pain management, and there are no studies on patients’ experiences of receiving or being treated with FNBs. In addition, there are no studies on staff´s experience of nursing care among patients with hip fractures who received an FNB.  Objectives: The overall aim of this thesis is to investigate the effect of a preoperative FNB in patients with hip fracture in terms of pain and complications, and, further, to describe experiences of pain and pain management among patients with hip fracture who received FNBs as well as staff´s experiences of treating them. The first two papers (I and II) investigate the effect of an FNB compared to opioids, with a focus on pain and complications. To gain a deeper understanding, the final two papers (III and IV) describe experiences of pain and pain management in patients with hip fractures who received an FNB, and the staff's experiences of nursing care with patients with hip fractures who received an FNB.  Methods: Papers I and II are based on a randomized controlled study which included patients aged 70 years or older with hip fractures, including those with cognitive impairment or dementia. Patients were randomized on arrival at the orthopaedic ward in terms of pain treatment to be administered; the options were FNB (with opioids if needed) or opioids alone. In paper I, 266 patients were included; the mean age was 84 years, 64% were women, and 45% had a dementia diagnosis. Paper II included 236 patients; the mean age was the same, 66% were women, and 46% had a dementia diagnosis. Pain assessment scales (self-rated VAS and VAS by proxy) was used preoperative to assess patients’ pain in rest. Nurses assessed the incidence of delirium using Nu-DESC, both pre- and postoperatively. In addition, a structural interview was performed with validated assessments 3 to 5 days after surgery by the author (AU). The assessments, nursing and medical records were subsequently evaluated by a specialist in geriatric medicine together with a trained research nurse in terms of complications, dementia, depression and delirium. Data collected in papers I and II were analysed using comparative and descriptive statistical analysis. In papers III and IV, semi-structured interviews were performed with patients (paper III) and with staff (nurses and assistant nurses, paper IV) based on interview guides with open-ended questions that offered opportunities for clarification and follow-up questions. In paper III, 23 patients with hip fractures aged 70 years or older who were treated with FNBs were interviewed, and in paper IV, staff working in the orthopaedic ward and emergency department with experience of caring for patients with hip fractures treated with FNBs were interviewed. The interviews were audio-recorded, transcribed and analysed using qualitative content analysis.  Results: The results in paper I showed that patients who received an FNB assessed lower pain scores over a period of 12 hours. Patients required smaller amounts of opioids and the number of patients requiring opioids was reduced compared with the group that received opioids alone. Overall, in paper II was it a high incidence of complications, common complications in both groups were pre and postoperative delirium (44% and 73%), nutritional problems (71%), anaemia (66%), constipation (64%) and urinary tract infection (45%), but no statistical difference was found between groups of those complications. The results in paper II showed that 39% of the patients who received an FNB and 49% of those who received opioids developed delirium before surgery, with no statistical difference. In paper III, patients described how the pain before surgery was experienced from no pain, to the worst possible pain and everything in between. They described how they dealt with pain in their own way, but also how they felt dependent on the staff's willingness to relieve the pain. They described that the pain treatment could be lifesaving, but that it could also create the feeling of a near-death experience. Further, some patients experienced memory loss regarding the time before surgery, which made it difficult to remember the pain and pain treatment they received.  Finally, in paper IV, the staff described that the FNB setting the agenda when caring for older patients with hip fracture in the preoperative phase. Nursing care required timing, with a need of staff orienting to time and customizing their communication. The outcome of the FNB affected nursing care, depending on if the FNB was successful or not successful. Further, staff faced ethical challenges regarding doing good and not harm and relieving pain and avoiding side-effects.      Conclusion: This thesis shows that FNB is a feasible preoperative pain management for patients with a hip fracture, even among those with dementia. Evidence-based guidelines are necessary as a basis for assessing pain and providing pain management, but staff should add an individualized pain management approach. Staff should evaluate every patient and see each patient as a unique individual with different experiences of pain and pain management to successfully relieve pain among patients with a hip fracture

Smärta och smärtbehandling med femoralisblockad : effekter och erfarenheter: äldre patienter och personalens perspektiv

Background: Older people with hip fractures are often frail with several comorbidities and roughly half of them have dementia disorders. Pain is common among patients with hip fracture and pain management in these patients is a challenge. Opioids are known to relieve pain while at rest but are not as effective in movement. One alternative to opioids is a femoral nerve block (FNB). Previous studies have shown that FNBs can decrease pain and the need for opioids, but these studies excluded patients with dementia. Few studies have investigated whether FNBs decrease the incidence of complications in general, and delirium in particular. These studies were also based on different types of nerve blocks and methods. Few studies have described patients’ experiences of pain and pain management, and there are no studies on patients’ experiences of receiving or being treated with FNBs. In addition, there are no studies on staff´s experience of nursing care among patients with hip fractures who received an FNB.  Objectives: The overall aim of this thesis is to investigate the effect of a preoperative FNB in patients with hip fracture in terms of pain and complications, and, further, to describe experiences of pain and pain management among patients with hip fracture who received FNBs as well as staff´s experiences of treating them. The first two papers (I and II) investigate the effect of an FNB compared to opioids, with a focus on pain and complications. To gain a deeper understanding, the final two papers (III and IV) describe experiences of pain and pain management in patients with hip fractures who received an FNB, and the staff's experiences of nursing care with patients with hip fractures who received an FNB.  Methods: Papers I and II are based on a randomized controlled study which included patients aged 70 years or older with hip fractures, including those with cognitive impairment or dementia. Patients were randomized on arrival at the orthopaedic ward in terms of pain treatment to be administered; the options were FNB (with opioids if needed) or opioids alone. In paper I, 266 patients were included; the mean age was 84 years, 64% were women, and 45% had a dementia diagnosis. Paper II included 236 patients; the mean age was the same, 66% were women, and 46% had a dementia diagnosis. Pain assessment scales (self-rated VAS and VAS by proxy) was used preoperative to assess patients’ pain in rest. Nurses assessed the incidence of delirium using Nu-DESC, both pre- and postoperatively. In addition, a structural interview was performed with validated assessments 3 to 5 days after surgery by the author (AU). The assessments, nursing and medical records were subsequently evaluated by a specialist in geriatric medicine together with a trained research nurse in terms of complications, dementia, depression and delirium. Data collected in papers I and II were analysed using comparative and descriptive statistical analysis. In papers III and IV, semi-structured interviews were performed with patients (paper III) and with staff (nurses and assistant nurses, paper IV) based on interview guides with open-ended questions that offered opportunities for clarification and follow-up questions. In paper III, 23 patients with hip fractures aged 70 years or older who were treated with FNBs were interviewed, and in paper IV, staff working in the orthopaedic ward and emergency department with experience of caring for patients with hip fractures treated with FNBs were interviewed. The interviews were audio-recorded, transcribed and analysed using qualitative content analysis.  Results: The results in paper I showed that patients who received an FNB assessed lower pain scores over a period of 12 hours. Patients required smaller amounts of opioids and the number of patients requiring opioids was reduced compared with the group that received opioids alone. Overall, in paper II was it a high incidence of complications, common complications in both groups were pre and postoperative delirium (44% and 73%), nutritional problems (71%), anaemia (66%), constipation (64%) and urinary tract infection (45%), but no statistical difference was found between groups of those complications. The results in paper II showed that 39% of the patients who received an FNB and 49% of those who received opioids developed delirium before surgery, with no statistical difference. In paper III, patients described how the pain before surgery was experienced from no pain, to the worst possible pain and everything in between. They described how they dealt with pain in their own way, but also how they felt dependent on the staff's willingness to relieve the pain. They described that the pain treatment could be lifesaving, but that it could also create the feeling of a near-death experience. Further, some patients experienced memory loss regarding the time before surgery, which made it difficult to remember the pain and pain treatment they received.  Finally, in paper IV, the staff described that the FNB setting the agenda when caring for older patients with hip fracture in the preoperative phase. Nursing care required timing, with a need of staff orienting to time and customizing their communication. The outcome of the FNB affected nursing care, depending on if the FNB was successful or not successful. Further, staff faced ethical challenges regarding doing good and not harm and relieving pain and avoiding side-effects.      Conclusion: This thesis shows that FNB is a feasible preoperative pain management for patients with a hip fracture, even among those with dementia. Evidence-based guidelines are necessary as a basis for assessing pain and providing pain management, but staff should add an individualized pain management approach. Staff should evaluate every patient and see each patient as a unique individual with different experiences of pain and pain management to successfully relieve pain among patients with a hip fracture

The Femoral Nerve Block Setting the Agenda for Nursing Care of Older Patients With hip Fractures—A Qualitative Study

Introduction: Hip fractures among older people are common worldwide, and it is often associated with preoperative pain. Due to increased comorbidity and high age, traditional pain relief can be a challenge. An alternative to traditional pain relief is a femoral nerve block, which is safe and suitable for anesthesia and analgesia for hip fractures among patients with or without dementia. It is essential to provide adequate pain management, and nurses report negative attitudes toward opioids and seem to prefer alternative pain management. To our knowledge, no study has focused on staff's experiences of nursing care for patients treated with femoral nerve block. Aim: To describe staff's experiences providing nursing care in preoperative pain and pain management to older patients with a hip fracture who received a femoral nerve block. Design: A qualitative exploratory design. Method: Semistructured interviews with 19 nurses or assistant nurses in an orthopedic ward or emergency department. They were experienced in caring for patients with hip fractures who received treatment with a femoral nerve block. The interviews were subjected to qualitative content analysis. Results: Staff described the femoral nerve block as setting the agenda when caring for older patients with hip fractures in the preoperative phase. The outcome of the femoral nerve block affected nursing care, depending on if the femoral nerve block was successful or not. Nursing care requires timing, with a need for staff orienting to time and customizing their communication. Further, staff faced ethical challenges regarding doing good and not harm, relieving pain, and avoiding side effects. Conclusions: The femoral nerve block was an important issue for nursing staff in patients with hip fractures in the preoperative phase. Our results point toward the benefits of giving femoral nerve blocks as soon as possible to facilitate nursing care, however, this should be studied in future research

Between Heaven and Hell : Experiences of Preoperative Pain and Pain Management among Older Patients with Hip Fracture

Introduction: Among older adults, hip fracture is a common and serious consequence of a fall. Preoperative pain is common and often severe among patients with hip fracture. Opioids are usually used but have many side effects. One alternative is a femoral nerve block, which has been shown to reduce pain and lower the need for opioids. However, to our knowledge no study has explored qualitatively how patients with hip fracture experience treatment with femoral nerve block. Objective: The aim of this study was to explore experiences of preoperative pain and pain management among older patients with hip fracture who had received a femoral nerve block.MethodA qualitative design with semi-structured interviews (n =23) conducted 2-6 days after surgery. Inclusion criteria were Swedish-speaking patients aged 70 years or older with hip fracture admitted to the orthopedic ward, treated with femoral nerve block before nursing actions. Data were analyzed with qualitative content analysis. Results: Our result revealed one theme, hovering between heaven and hell, with five subthemes: how the pain was described - no pain, to worst pain and everything in between; they were dealing with pain in their own way; felt dependent on staff?s willingness to relieve pain; pain management could be lifesaving and a near-death experience; and how they experienced memory loss with respect to the pain and pain management. Conclusion: The experience of pain and pain management was described as hovering between heaven and hell. We conclude that independent of which pain management given, staff should have an individualized pain mangement approach towards the patient in order to achieve well managed pain

Complications with focus on delirium during hospital stay related to femoral nerve block compared to conventional pain management among patients with hip fracture : A randomised controlled trial

Introduction: Patients with hip fracture often suffer complications leading to increased mortality and morbidity. Pain management are important, but opioids has many side effects. The aim of this study was to investigate whether Femoral Nerve Block (FNB) can reduce complications during hospital stay, with special focus on delirium compared to conventional pain management with opioids among patients with hip fracture, including those with dementia. Patients & Methods: In a randomized controlled trial involving patients >70 years with hip fracture (trochanteric and cervical), including those with dementia. Preoperatively, patients (n=236) were consecutively assigned to receive FNB and opioids if required (intervention group, n = 116) or conventional pain management using opioids if required (control group, n = 120). Delirium was set according to different assessments and DSM-IV-TR criteria. Other complications were set by a specialist in geriatric medicine and a trained research nurse according to a predefined protocol. Results: Most patients, 157 (66%), were women, mean age was 84 (+/- 6.7) years and 109 (46%) patients had dementia disorders. Forty-four patients (38.9%) developed delirium preoperatively in the intervention group compared to 59 (49.2%) patients in the control group (p=0.116). Common postoperative complications were pre- and postoperative delirium, nutritional problems, anaemia, constipation and urinary tract infection with no significant difference between the groups. In the subgroup analysis among patients with dementia, a large proportion developed delirium postoperative (96.3%) and they had a long duration of delirium during hospital stay (5.9 +/- 1.8), however no difference between the groups. Conclusion: Despite less preoperative pain and need of opioids, FNB did not reduce the incidence of complications. However, a preoperative FNB may result in less preoperative delirium, but this should be further investigated. As pain treatment, FNB is a good alternative with few documented adverse effects in order to reduce pain and opioids among patients with hip fracture