Hip fracture is associated with moderate-to-severe pain, both pre- and post-operatively. Emergent or semi-emergent surgical repair is considered mandatory in most cases. The patients are usually elderly, often with comorbidities and frequently suffer from some blood-loss or hypovolemia caused by fracture and immobility. Perioperative delirium may occur in up to 50% of the patients. The aim of this systematic review was to develop recommendations for optimal pain management after hip fracture. A systematic review utilising the PROSPECT methodology was undertaken. Randomised controlled trials, systematic reviews and meta-analysis published in the English language between 04 April 2005 and 12 May 2021, evaluating the effects of analgesic and anaesthetic interventions were retrieved from MEDLINE, Embase and Cochrane Databases. A total of 60 studies met the inclusion criteria. For patients having hip fracture, adequate analgesic treatment should be initiated as needed pre-operatively and repeated or continued post-operatively. Paracetamol and non-steroidal anti-inflammatory drugs or cyclooxygenase-2 specific inhibitors are recommended. A single shot femoral nerve block or a single shot fascia iliaca compartment block is recommended. The choice between femoral nerve block or a fascia iliaca compartment block should be made according to local expertise. The postoperative regimen should further include scheduled ‘round-the-clock’ paracetamol and non-steroidal anti-inflammatory drugs or cyclooxygenase-2 specific inhibitors with opioids used for rescue. Potential contraindications in this fragile patient population should be considered carefully. Some other interventions, although effective, carry risks and consequentially were omitted from the recommendations in routine cases, while others were not recommended due to insufficient, inconsistent or lack of evidence. Hip arthroplasty will often be the surgical procedure relevant for hip fracture and has been studied recently by the PROSPECT group. Intrathecal morphine, local infiltration anaesthesia and dexamethasone were then recommended in the elective arthroplasty setting, in addition to those recommendations retrieved from the literature on hip fracture surgery.
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