Fascia iliaca compartment block reduces morphine requirement pre-operatively for patients with fractured neck of femur

Fascia iliaca compartment block (FICB) as pain treatment in older persons with suspected hip fractures in prehospital emergency care - A comparative pilot study

BACKGROUND

Older persons with a suspected hip fracture and suffering considerable pain are common patients in the emergency medical services (EMS). Pain treatment needs to be improved and fascia iliaca compartment block (FICB) can be one option. The purpose of this paper was to analyse prehospital pain in patients with a suspected hip fracture under EMS care and to compare standard treatment and FICB.

METHODS

An evaluation of a retrospective case-control study comprising 135 patients from a pilot project with FICB in an EMS organisation in Sweden. The control patients were matched with FICB patients. Pain was assessed on the arrival of the EMS and on arrival in hospital.

RESULTS

In all, 27 patients received FICB and 108 had standard pain treatment. There was a significant reduction in pain in both groups. However, there was a more marked reduction in pain among patients who received FICB than in the control group. So, for static pain, 56% experienced a reduction in pain in the FICB group versus 30% among controls (p < 0.01). The corresponding values for dynamic pain were 85% and 59% (p < 0.01).

CONCLUSION

FICB can be a good supplement to standard prehospital pain treatment in patients with suspected hip fractures.

Can emergency nurses safely and effectively insert fascia iliaca blocks in patients with a fractured neck of femur? A prospective cohort study in an Australian emergency department

AIMS AND OBJECTIVES

To compare the effectiveness and safety of ultrasound-guided fascia iliaca block (FIB) insertion in patients with fractured neck of femur by trained emergency nurses with insertion by doctors.

BACKGROUND

The FIB is an effective and safe form of analgesia for patients with hip fracture presenting to the emergency department (ED). While it has traditionally been inserted by medical doctors, no evidence exists comparing the effectiveness and safety of FIB insertion by nurses compared with doctors.

DESIGN

A prospective cohort study.

METHODS

The study was conducted in an Australian metropolitan ED. Patients admitted to the ED with suspected or confirmed fractured neck of femur had a FIB inserted under ultrasound guidance by either a trained emergency nurse or doctor. A retrospective medical record audit was undertaken of consecutive ED patients presenting between January 2013-December 2017. Reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cohort studies.

RESULTS

Of the 472 patients eligible for a FIB, 322 (68%) had one inserted. A majority were inserted by doctors (n = 207, 64.3%) with 22.4% (n = 72) by nurses and in 13.3% (n = 43) of patients the clinician was not documented. There were no differences between the nurse-inserted and doctor-inserted groups for mean pain scores 1 hr post-FIB insertion; clinically significant reduction (≥30%) in pain score 1 hr post-FIB insertion; pain score 4 hr post-FIB insertion; delirium incidence; opioid use post-FIB insertion; or time to FIB insertion. No adverse events were identified in either group.

CONCLUSION

Insertion of FIBs by trained emergency nurses is as effective and safe as insertion by doctors in patients with fractured neck of femur in the ED. Senior emergency nurses should routinely be inserting FIB as a form of analgesia for patients with hip fracture.

RELEVANCE TO CLINICAL PRACTICE

Our study showed trained emergency nurses can safely and effectively insert fascia iliaca blocks in patients with hip fractures. Pain was significantly reduced in a majority of patients with no reported complications. Emergency nurses should be trained to insert fascia iliaca blocks in patients with hip fractures.

Peripheral nerve blocks for hip fractures in adults

BACKGROUND

This review was published originally in 1999 and was updated in 2001, 2002, 2009, 2017, and 2020. Updating was deemed necessary due to the high incidence of hip fractures, the large number of official societies providing recommendations on this condition, the possibility that perioperative peripheral nerve blocks (PNBs) may improve patient outcomes, and the major role that PNBs may play in reducing preoperative and postoperative opioid use for analgesia.

OBJECTIVES

To compare PNBs used as preoperative analgesia, as postoperative analgesia, or as a supplement to general anaesthesia versus no nerve block (or sham block) for adults with hip fracture. Outcomes were pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction, chest infection, death, time to first mobilization, and costs of an analgesic regimen for single-injection blocks. We undertook the update to look for new studies and to update the methods to reflect Cochrane standards.

SEARCH METHODS

For the updated review, we searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 11), in the Cochrane Library; MEDLINE (Ovid SP, 1966 to November 2019); Embase (Ovid SP, 1974 to November 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to November 2019), as well as trial registers and reference lists of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing use of PNBs compared with no nerve block (or sham block) as part of the care provided for adults 16 years of age and older with hip fracture.  DATA COLLECTION AND ANALYSIS: Two review authors independently screened new trials for inclusion, assessed trial quality using the Cochrane Risk of Bias-2 tool, and extracted data. When appropriate, we pooled results of outcome measures. We rated the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 49 trials (3061 participants; 1553 randomized to PNBs and 1508 to no nerve block (or sham block)). For this update, we added 18 new trials. Trials were published from 1981 to 2020. Trialists followed participants for periods ranging from 5 minutes to 12 months. The average age of participants ranged from 59 to 89 years. People with dementia were often excluded from the included trials. Additional analgesia was available for all participants. Results of 11 trials with 503 participants show that PNBs reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.05, 95% confidence interval (CI) -1.25 to -0.86; equivalent to -2.5 on a scale from 0 to 10; high-certainty evidence). Effect size was proportionate to the concentration of local anaesthetic used (P = 0.0003). Based on 13 trials with 1072 participants, PNBs reduce the risk of acute confusional state (risk ratio (RR) 0.67, 95% CI 0.50 to 0.90; number needed to treat for an additional beneficial outcome (NNTB) 12, 95% CI 7 to 47; high-certainty evidence). For myocardial infarction, there were no events in one trial with 31 participants (RR not estimable; low-certainty evidence). From three trials with 131 participants, PNBs probably reduce the risk for chest infection (RR 0.41, 95% CI 0.19 to 0.89; NNTB 7, 95% CI 5 to 72; moderate-certainty evidence). Based on 11 trials with 617 participants, the effects of PNBs on mortality within six months are uncertain due to very serious imprecision (RR 0.87, 95% CI 0.47 to 1.60; low-certainty evidence). From three trials with 208 participants, PNBs likely reduce time to first mobilization (mean difference (MD) -10.80 hours, 95% CI -12.83 to -8.77 hours; moderate-certainty evidence). One trial with 75 participants indicated there may be a small reduction in the cost of analgesic drugs with a single-injection PNB (MD -4.40 euros, 95% CI -4.84 to -3.96 euros; low-certainty evidence). We identified 29 ongoing trials, of which 15 were first posted or at least were last updated after 1 January 2018.  AUTHORS' CONCLUSIONS: PNBs reduce pain on movement within 30 minutes after block placement, risk of acute confusional state, and probably also reduce the risk of chest infection and time to first mobilization. There may be a small reduction in the cost of analgesic drugs for single-injection PNB. We did not find a difference for myocardial infarction and mortality, but the numbers of participants included for these two outcomes were insufficient. Although randomized clinical trials may not be the best way to establish risks associated with an intervention, our review confirms low risks of permanent injury associated with PNBs, as found by others. Some trials are ongoing, but it is unclear whether any further RCTs should be registered, given the benefits found. Good-quality non-randomized trials with appropriate sample size may help to clarify the potential effects of PNBs on myocardial infarction and mortality.

Fascia Iliaca Regional Anesthesia in Hip Fracture Patients Revisited: Which Fractures and Surgical Procedures Benefit Most?

OBJECTIVES

Perioperative fascia iliaca regional anesthesia (FIRA) decreases pain in hip fracture patients. The purpose of this study is to determine which hip fracture types and surgical procedures benefit most.

DESIGN

Prospective observational study compared with a retrospective historical control.

PATIENTS/PARTICIPANTS

Patients older than 60 years who received perioperative FIRA were compared with a historical cohort not receiving FIRA.

SETTING

This study was conducted at a Level 1 trauma center.

MAIN OUTCOME MEASUREMENTS

The primary outcome was morphine milliequivalents (MME) consumed during the index hospitalization. Fracture pattern-specific preoperative and postoperative MME consumption and surgical procedure-specific postoperative MME consumption was compared between the FIRA and non-FIRA groups.

RESULTS

A total of 949 patients were included in this study, with 194 (20.4%) patients in the prospective protocol group. There were no baseline differences between cohorts. Preoperatively, only femoral neck fracture patients receiving FIRA used fewer MME (P < 0.001). Postoperatively, femoral neck fracture patients receiving FIRA used fewer MME on postoperative day (POD) 1 (P = 0.027) and intertrochanteric fracture patients used fewer MME on POD1 and POD2 (P = 0.013; P = 0.002). Cephalomedullary nail patients receiving FIRA used fewer MME on POD1 and POD2 (P = 0.004; P = 0.003). Hip arthroplasty patients receiving FIRA used fewer MME on POD1 (P = 0.037). Percutaneous pinning and sliding hip screw patients had no significant MME reduction from FIRA.

CONCLUSIONS

Preoperatively, patients with femoral neck fractures benefit most from FIRA. Postoperatively, both patients with femoral neck fractures and intertrochanteric fractures benefit from FIRA. Patients undergoing cephalomedullary nail fixation or hip arthroplasty benefit most from FIRA postoperatively.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Comparison in Outcomes of Preoperative Single-shot versus Continuous Catheter Fascia Iliaca Regional Anesthesia in Geriatric Hip Fracture Patients

BACKGROUND

Fascia iliaca nerve blocks relieve pain in geriatric hip fracture patients and can be administered via a single-shot or continuous catheter. We compared perioperative opioid consumption and pain scores between these two blocks.

METHODS

We performed a prospective, observational cohort study, including geriatric hip fracture patients who received a preoperative block. We compared morphine milligram equivalent (MME) consumption and visual analog scale (VAS) pain scores between single-shot and continuous fascia iliaca blocks at multiple time points: preoperative and on postoperative (POD) day 0, 1, and 2. We compared the change in preoperative total and hourly opioid consumption before and after block placement within and between groups. Secondary outcomes included opioid related adverse events, length of stay, and readmission rates.

RESULTS

107 patients were analyzed, 66 received a single-shot and 41 a continuous block. No significant differences were found between both blocks at any time point for median MME consumption or pain scores. MME [IQR]: preoperative 20.5 [6.0,48.8] vs. 24.0 [8.8,48.0], p=0.95; POD0 6.0 [0.0,18.6] vs. 10.0 [0.0,14.0], p=0.52; POD1 12.0 [0.0,30.0] vs. 18.0 [5.0,24.0], p=0.69; POD2 6.0 [0.0,21.2] vs. 12.0 [0.0,24.0], p=0.54. VAS [IQR]: preoperative 4.0 [2.2,5.3] vs. 4.6 [3.2,5.3], p=0.34; POD0 1.3 [0.0,3.7] vs. 2.5 [0.0,3.6], p=0.73; POD1 2.9 [1.7,4.4] vs. 3.7 [1.5,4.7], p=0.59; POD2 2.4 [1.0,4.4] vs. 3.3 [1.9,4.2], p=0.18. Preoperative MME/hr significantly decreased after the block for both groups: 1.05 [0.0,2.2] to 0.0 [0.0,0.0], p < 0.001; 1.4 [0.6,3.1] to 0.0 [0.0,0.1], p < 0.001. The reduction in MME/hr between groups was not significantly different: 0.9 [0.0,1.9] vs. 1.4 [0.6,3.1], p = 0.067. We found no significant differences in secondary outcomes between groups.

CONCLUSIONS

We report no differences in opioid use and pain scores between single-shot and continuous catheter fascia iliaca nerve blocks. Both blocks similarly reduce preoperative opioid consumption.

Pain Management with Early Regional Anesthesia in Geriatric Hip Fracture Patients

BACKGROUND

Geriatric hip fracture patients are susceptible to the adverse effects of opioid-induced analgesia. Fascia iliaca blocks (FIBs) have emerged as an analgesic technique for this population. There are limited data on a preoperative FIB's effect on perioperative opioid intake. We hypothesized that preoperative FIB would reduce perioperative opioid consumption, measured in morphine milliequivalents (MMEs).

DESIGN

This is a prospective observational study.

SETTING

A level 1 trauma center in California.

PARTICIPANTS

From March 2017 to December 2017, patients 65 years and older presenting with a hip fracture received a preoperative FIB and were prospectively observed. This cohort was compared with a historical control.

INTERVENTION

All prospectively enrolled patients were given FIBs. For a single-shot FIB, a 30- to 40-mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine was injected. For a continuous FIB, a bolus of 10 to 20 mL of 0.2% bupivacaine was injected, followed by a continuous infusion of 0.2% bupivacaine at 6 mL/h ending on the morning of postoperative Day 1.

RESULTS

A total of 725 patients were included in this study, with 92 in the prospectively collected cohort. The mean age of this cohort was 84.2 (standard deviation = 8.4) years, and 69.2% were female. Patients who received a preoperative FIB consumed less MME preoperatively, 18.0 (interquartile range = 6.0-44.5) versus 29.5 (interquartile range = 6.0-56.5) (P = .007), with no change in pain scores. No differences were found in postoperative opioid consumption between groups. There was no difference in MME or pain score in patients with dementia. Subgroup analysis based on fracture pattern (femoral neck and intertrochanteric) demonstrated a significant decrease in preoperative MME consumption in femoral neck fractures only, 12.0 (interquartile range = 5.0-24.0) versus 29.0 (interquartile range = 12.0-59.0) (P < .001).

CONCLUSION

FIBs reduce preoperative opioid intake and have low rates of opioid-related adverse events in geriatric hip fracture patients.

LEVEL OF EVIDENCE

The level of evidence was II.

Applications and critical evaluation of fascia iliaca compartment block and quadratus lumborum block for orthopedic procedures

Anterior section of the hip joint capsule is innervated by femoral nerve and obturator nerve, and posterior section is innervated by the nerve to quadratus femoris muscle and occasionally by the superior gluteal (posterolateral region) and sciatic nerve (posterosuperior region). One of the regional anesthesia options for hip surgery is the fascia iliaca compartment block (FICB) that affects nerves important for hip innervation and sensory innervation of the thigh - femoral, obturator and lateral femoral cutaneous nerve. FICB can be easily performed and is often a good solution for management of hip fractures in emergency departments. Its use reduces morphine pre-operative requirement for patients with femoral neck fractures and can also be indicated for hip arthroplasty, hip arthroscopy and burn management of the region. Quadratus lumborum block (QLB) is a block of the posterior abdominal wall performed exclusively under ultrasound guidance, with still unclarified mechanism of action. When considering hip surgery and postoperative management, the anterior QLB has shown to reduce lengthy hospital stay and opioid use, it improves perioperative analgesia in patients undergoing hip and proximal femoral surgery compared to standard intravenous analgesia regimen, provides early and rapid pain relief and allows early ambulation, thus preventing deep vein thrombosis and thromboembolic complications etc. However, some nerve branches responsible for innervation of the hip joint are not affected by QLB, which has to be taken into consideration. QLB has shown potential for use in hip surgery and perioperative pain management, but still needs to be validated as a reliable treatment approach.

Fascia-iliaca compartment block vs intra-articular hip injection for preoperative pain management in intracapsular hip fractures: A blind, randomized, controlled trial

BACKGROUND

The aim of this study was to compare the fascia-iliaca compartment block and the intra-articular hip injection in terms of pain management and the need for additional systemic analgesia in the preoperative phase of intracapsular hip fractures.

METHODS

Patients >65 years old with an intracapsular hip fracture were randomized in this prospective, blind, controlled, parallel trial in a Level-I trauma center. Patients were randomly assigned to receive either the fascia-iliaca compartment block (cohort FICB) or the intra-articular hip injection (cohort IAHI) upon admission to the emergency department. The primary outcome was pain relief at 20 min, 12 h, 24 h and 48 h after the regional anesthesia, both at rest and during internal rotation of the fractured limb. The Numeric Rating Scale was used. Residual pain was managed with the same protocol in all patients. Additional analgesic drug administration during the 48 h from admission was recorded.

RESULTS

A total of 120 patients with comparable baseline characteristics were analyzed in this study: the FICB group consisted of 70 subjects, while the IAHI group consisted of 50 subjects. Pain was significantly lower in the IAHI group during movement of the fractured limb at 20 min (p < 0.05), 12 h (p < 0.05), 24 h (p < 0.05) and 48 h (p < 0.05). In the FICB cohort 72.9% of patients needed to take oxycodone, in contrast to 28.6% of the IAHI cohort (p < 0.05). In the FICB cohort 14.09 ± 11.57 mg of oxycodone was administered, while in the IAHI cohort 4.38 ± 7.63 mg (p < 0.05). No adverse events related to either technique were recorded.

CONCLUSIONS

Intra-articular hip injection provides better pre-operatory pain management in elder patients with intracapsular hip fractures compared to the fascia-iliaca compartment block. It also reduced the need for supplementary systemic analgesia.

LEVEL OF EVIDENCE

Therapeutic Level I.

Can we reduce morphine use in elderly, proximal femoral fracture patients using a fascia iliac block?

Proximal femoral fractures are becoming increasingly common with an ageing population. Many patients have multiple comorbidities increasing their risk of opiate complications. 40 consecutive patients presenting with a proximal femoral fracture to a trauma centre in the UK were given either a Fascia Iliaca Block (FIB) with oral analgesia or just oral analgesia to control their pre-operative pain. Numeric pain scores and morphine consumption were used as outcome measures. Patients receiving a FIB had significant reduction in their pain scores compared to patients only receiving oral pain relief. There was also a significant reduction in both the actual oral morphine taken and the renal calculated level of morphine products in the group receiving the FIB. Patients undergoing a FIB required almost 50 mg less oral morphine pre-operatively. Nerve blocks should be used routinely to help pre-operative pain in proximal femoral fracture patients and to reduce the amount of morphine products prescribed. This prevents potential opiate complications in a highly susceptible cohort of patients often suffering with impaired renal function as a co-morbidity.

Provision of fascia iliaca compartment block in the acute management of proximal femoral fractures: A national observational study of UK hospitals

AIMS

Fascia iliaca compartment block (FICB) is a simple regional anaesthetic block that has been shown to be superior to other regional anaesthetic blocks with regards to success rate and analgesic efficacy in the acute management of proximal femoral fractures. The objective was to quantitatively assess the provision of FICB for patients with proximal femoral fractures in the UK.

METHODS

A national observational study of all acute medical trusts in the UK (n=187) was conducted. Each trust was contacted and asked to complete a freedom of information request relating to the use of regional nerve blocks in patients with a proximal femoral fracture between 2/11/2014 and 2/11/2015. The STROBE checklist was used to help design and conduct the study.

RESULTS

144/187(77.0%) of medical trusts across the UK responded. Overall, 61.8% of trusts routinely performed FICB for patients with a neck of femur (NOF) fracture. The number of trusts with a specific standardised proforma for NOF fracture patients was 127/144 (88.2%), while 83/144 (57.6%) included a section relating to FICB. 50/144 (34.7%) of trusts had no hospital related guideline for FICBs in NOF fracture patients. The use of analgesia in NOF fracture patients was audited in 95/144 (66.0%) of trusts. Where FICB was administered, the procedure was typically conducted by specialists in emergency medicine (50.6%), anaesthetics (34.6%) and orthopaedics (14.8%). Common reasons for lack of FICB provision include: lack of trained staff, resumption of adequate analgesia via other methods and a perception that there is insufficient evidence for routine use of peripheral nerve blocks improving survival and outcomes.

CONCLUSIONS

Administration of regional nerve blocks for patients with proximal femoral fractures is increasing but variable between trusts. Further work should examine how barriers to the delivery of FICBs might be addressed.

Efficacy of fascia iliaca compartment nerve block as part of multimodal analgesia after surgery for femoral bone fracture

BACKGROUND

Fascia iliaca compartment nerve block (FICNB) has been an established technique for postoperative analgesia after surgery for femoral bone fracture. FICNB is technically easy, effective for postoperative pain control after operation for femoral bone fracture and decreases the complications induced by systemic analgesic drugs. The severity of postoperative pain is affected by genetics, cultural and social factors across the world. In this study we assessed the efficacy of fascia iliaca compartment nerve block when it is used as part of multimodal analgesia after surgery for femoral bone fracture.

METHODS

An institution-based case control study was conducted from September, 2013 to May, 2014. All patients who had been operated on under spinal anesthesia for femoral bone fracture were included. The patients divided into a FICNB group (n=20) and a control group (n=20). The FICNB group was given 30 mL of 0.25% bupivacaine at the end of the operation. Postoperative pain was assessed within the first 24 hours, i.e. at 15 minutes, 2 hours, 6 hours, 12 hours and 24 hours using 100 mm visual analogue scale (VAS), total analgesic consumption, and the time for the first analgesic request.

RESULTS

VAS pain scores were reduced within the first 24 hours after operation in the FICNB group compared wtih the control group. VAS scores at 2 hours were taken as median values (IQR) 0.00 (0.00) vs.18.00 (30.00), P=0.001; at 6 hours 0.00 (0.00) vs. 34.00 (20.75), P=0.000; at 24 hours 12.50 (10.00) vs. 31.50 (20.75), P=0.004; and at 12 hours (17.80±12.45) vs. (29.95±12.40), P=0.004, respectively. The total analgesic consumption of diclofenac at 12 and 24 hours was reduced in the FICNB group, and the time for the first analgesic request was significantly prolonged (417.50 vs. 139.25 minutes, P=0.000).

CONCLUSIONS

A single injection for FICNB could lead to postoperative pain relief, reduction of total analgesic consumption and prolonged time for the first analgesic request in the FICNB group after surgery for femoral bone fracture. We recommend FICNB for analgesia after surgery for femoral bone fracture and for patients with femoral bone fracture at the emergency department.