Pain Management for Elderly Male with Hip Prosthesis Dislocation
Add NSAIDs (if renal function permits) or proceed directly to opioids for breakthrough pain, while urgently arranging femoral nerve block or fascia iliaca compartment block as the definitive analgesic intervention for this orthopedic emergency.
Immediate Analgesic Escalation
Continue Acetaminophen as Foundation
- Regular IV or oral acetaminophen 1000 mg every 6 hours must continue as the mandatory baseline treatment, as it significantly decreases supplementary opioid requirements in elderly hip trauma patients 1, 2.
- This forms the non-negotiable foundation of multimodal analgesia regardless of pain severity 1, 2.
Add NSAIDs with Critical Screening
- Before prescribing NSAIDs, verify renal function immediately - NSAIDs are absolutely contraindicated in any degree of renal impairment 1, 2, 3.
- If creatinine clearance is adequate and no contraindications exist (no history of GI bleeding, cardiovascular disease, or concurrent anticoagulation), add ibuprofen 400 mg every 6 hours or a COX-2 selective inhibitor 1, 2.
- Co-prescribe a proton pump inhibitor if NSAIDs are used, particularly critical if the patient takes ACE inhibitors, diuretics, or antiplatelets due to drug interactions 1.
- NSAIDs are generally not recommended in elderly hip fracture/dislocation patients due to high prevalence of renal dysfunction and polypharmacy 1.
Opioids for Breakthrough Pain Only
- If NSAIDs are contraindicated or pain remains severe despite acetaminophen plus NSAIDs, add hydrocodone or oxycodone at reduced dosing for breakthrough pain only 2, 4.
- In elderly patients, start at half the standard adult dose due to increased sensitivity and risk of respiratory depression 4.
- In patients with any renal impairment, reduce both dose and frequency of opioids by 50-75% as hydrocodone is substantially excreted by the kidney 2, 4.
- Avoid codeine entirely in elderly patients due to constipating, emetic, and cognitive dysfunction effects 2, 5.
- Tramadol can be considered but requires dose reduction in renal dysfunction and carries seizure risk 1.
Definitive Pain Management: Regional Anesthesia
Femoral Nerve Block or Fascia Iliaca Compartment Block - Priority Intervention
- Femoral nerve block or fascia iliaca compartment block should be arranged urgently as the primary analgesic modality for hip prosthesis dislocation, providing superior pain control with fewer side effects compared to systemic opioids 1, 2, 5, 3.
- Continuous catheter techniques are superior to single-shot blocks for extended analgesia in this population 2, 5, 3.
- Regional anesthesia reduces acute confusional state, decreases chest infection rates, promotes earlier mobilization, and significantly reduces morphine consumption 3.
- Before performing any nerve block, carefully evaluate anticoagulation status to avoid bleeding complications 1, 2.
Critical Monitoring and Pitfalls
Renal Function Surveillance
- Assess renal function before and during NSAID/opioid therapy, as elderly patients are particularly susceptible to volume-dependent renal failure 2.
- Hypovolemia is common in hip trauma patients - encourage oral fluid intake rather than routine IV fluids 1.
Cognitive Dysfunction Prevention
- Monitor for postoperative cognitive dysfunction and delirium, which occurs in 25% of hip fracture patients and interrupts rehabilitation 1, 3.
- Opioids significantly worsen delirium risk - adequate analgesia through regional techniques prevents this complication 1.
- Avoid cyclizine due to antimuscarinic side effects in elderly patients 1.
Pain Assessment During Mobilization
- Include pain evaluation as part of routine nursing observations, as analgesia requirements vary considerably during remobilization after hip dislocation 1, 3.
- Pain during physical therapy often differs substantially from resting pain, requiring careful titration 3.