The use of intrathecal opioids should be restricted to <=25mcg fentanyl.
Opioid co-administration prolongs postoperative analgesia with equipotent doses of intrathecal local anaesthetic (8 hours morphine, 2 hours fentanyl) .
Opioid co-administration allows lower doses of intrathecal local anaesthetic to be used, but in this combination does not prolong postoperative analgesia compared to standard dose of intrathecal local anaesthetic alone .
- there is no evidence for these in hip fracture
- diamorphine is preferred by most anaesthetists in the UK , but there is no evidence for what dose of diamorphine provides the optimal risk/benefit ratio in hip fracture patients.
- intrathecal (dia)morphine is associated with more side-effects than fentanyl, including itching, respiratory depression, urinary retention and nausea and vomiting 
- anecdotally, intrathecal opioids increase somnolence and confusion in hip fracture patients, but this has not been confirmed by research
- postoperatively, the painful hip fracture is fixed
- postoperative analgesia is provided by pre-spinal nerve block
- minimal effective doses of intrathecal morphine and fentanyl should be used .
Urgent work needs to be done comparing the effect/side-effect profile of low-dose 0.5% bupivacaine + opioid vs. low-dose 0.5% bupivacaine + nerve block in hip fracture patients.
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2. Pöpping DM, Elia N, Wenk M, Tramèr MR. Combination of a reduced dose of an intrathecal local anesthetic with a small dose of an opioid: a meta-analysis of randomized trials. Pain 2013; 154: 1383-90.
3. White SM, Moppett IK, Griffiths R et al. Outcomes after anaesthesia for hip fracture surgery. Secondary analysis of prospective observational data from 11 085 patients included in the UK Anaesthesia Sprint Audit of Practice (ASAP 2). Anaesthesia 2016; 71: 506-14.