Studies have suggested that epidural anesthesia

This preview shows page 8 - 9 out of 34 pages.

Studies have suggested that epidural anesthesia instituted pre- operatively reduces perioperative myocardial ischemia more effectively than does the use of parenteral narcotics. 48,49 Cur- rently, there is insufficient evidence to determine if the use of nerve blocks for postoperative analgesia confers any sub- stantial benefit compared with other analgesic methods. 50 The control of postoperative pain is important in preventing delirium. Higher pain scores at rest during the first 3 postopera- tive days are associated with postoperative delirium in patients undergoing noncardiac surgery. 51 Increased levels of preopera- tive and postoperative pain are risk factors for the development of postoperative delirium. 52 In the hip fracture population, Mor- rison et al 53 found that cognitively intact individuals with poorly controlled pain were 9 times more likely to become delirious. When selecting narcotics for pain management, there is no difference in cognitive outcome when comparing fentanyl, morphine, and hydromorphone 54 ; meperidine is the only narcotic that has been definitively associated with delirium, and it should be avoided. 55,56 With regard to the mode of nar- cotic administration, there is no difference in cognitive out- come between intravenous and epidural administration. 54 There is no evidence that postoperative delirium limits the use of on-demand patient-controlled analgesia, 57 but 1 prospec- tive case series showed an association between oral opioid administration and a decreased risk of developing delirium compared with intravenous patient-controlled analgesia. 52 To summarize the relationship between postoperative delirium and pain management with narcotics in hip fracture patients, the strongest evidence supports avoiding meperi- dine, and there is only weak evidence that the mode of admin- istration is an important factor. Opioids themselves may induce delirium, and elderly patients may have increased cerebral sensitivity to them. 58 To circumvent these effects, nonopioid analgesics are increas- ingly used as a part of a multimodal pain management regimen. Two randomized studies have shown that nonopioid-based analgesics decrease postoperative pain and the need for opioids. 59,60 In addition, a meta-analysis has shown that non- steroidal anti-inflammatories (NSAIDs) are associated with a 30 % to 50 % decrease in opioid consumption and decreased morphine-associated side effects. 61 Therefore, a multimodal approach to pain management using NSAIDs or other nono- pioids, such as acetaminophen, allows lower doses of medica- tions to be used, thus helping to reduce potential side effects. 62 ± Good control of postoperative pain reduces delirium and improves a patient’s ability to participate in rehabilitation. Wound Care and Infection Prevention (S. Kates). There is consid- erable variation in the management of postoperative wounds.

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture