RecommendationConsider adding nerve blocks if paracetamol and opioids do not provide sufficient preoperative pain relief, or to limit opioid dosage. Nerve blocks should be administered by trained personnel. Do not use nerve blocks as a substitute for early surgery.
Relative values of different outcomesThis group of patients is most commonly elderly and frail and pain is one of the main physiological and psychological stresses they face. Therefore, the GDG considered pain relief (for example as indicated by the need for ‘breakthrough analgesia’) to be the most important outcome. The GDG also considered adverse events outcomes to be important. Adequate pain relief is beneficial. Reduction in the required administration of opioids and the associated side effects may also be an important outcome.
Trade off between clinical benefits and harmsLocal nerve blocks are effective and may serve as a means of reducing the need for, and side effects of, opioids and other analgesia. However, as there they are associated with a very rare incidence of nerve damage, administering them in a busy casualty department may require a rolling programme of training junior doctors or nurses to be competent with this technique.
Economic considerationsThe additional cost of nerve blocks versus the cost of opioid drugs may be offset by savings in the resources that would be required to treat the side effects of opioids. The GDG agrees that the additional costs are likely to be offset by the beneficial outcomes of ensuring adequate analgesia.
Quality of evidenceThere are a limited number of clinical trials that have examined the effectiveness of nerve blocks in conjunction with general anaesthesia. Some studies have looked at the impact of inserting nerve blocks before the surgical procedure, to see if this may reduce analgesic requirements and improve pain management. These studies show that nerve blocks reduce the degree of pain compared to systemic analgesia alone and that they may have fewer side effects compared to systemic analgesia.
Other considerationsAlthough studies have shown that nerve blocks are better than systemic analgesia at relieving pain, the GDG considered that this should not be the be first line treatment. The GDG wished to ensure that the administration of analgesics is done in a step wise approach as some patients may benefit from simple analgesics such as paracetamol and therefore avoid the more serious side effects of stronger analgesics.

From: 7, Analgesia

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The Management of Hip Fracture in Adults [Internet].
NICE Clinical Guidelines, No. 124.
National Clinical Guideline Centre (UK).
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