Single fascia iliaca compartment block for post-hip fracture pain relief

Managing Delirium in the Emergency Department: An Updated Narrative Review

Purpose of Review

Emergency departments (EDs) are facing an epidemic of overcrowding and ED boarding, particularly of older adults who often present with, or develop, delirium in the ED. Delirium is associated with increased complications, longer hospital length of stay, mortality, and costs to the healthcare system. However, we only have limited knowledge of how to successfully prevent and treat delirium in the ED in a pragmatic, sustainable, and cost-effective way. We present a narrative review of recent literature of delirium prevention and treatment programs in the ED. We aim to describe the components of successful delirium management strategies to be used by EDs in building delirium management programs.

Recent Findings

We reviewed 10 studies (2005-2023) that report delirium interventions in the ED, and describe the different components of these interventions that have been studied. These interventions included: optimizing hemodynamics and oxygenation, treating pain, hydration and nutrition support, avoiding sedative hypnotics, antipsychotics and anticholinergics, promoting sleep, sensory stimulation, limiting the time spent in the ED, educating providers and staff, and developing multidisciplinary delirium protocols integrated into the electronic health record.

Summary

Through our narrative review of the recent literature on delirium prevention and treatment programs in the ED, we have identified nine components of successful delirium prevention strategies in the ED. We also discuss three high priority areas for further research including identification of most effective components of delirium prevention strategies, conduct of additional high-quality trials in non-hip.

Implementation of a Fascia Iliaca Compartment Block Program in Geriatric Hip Fractures: The Experience at a Level I Academic Trauma Center

OBJECTIVES

Determine adherence to a newly implemented protocol of fascia iliaca compartment block (FICB) in geriatric hip fractures.

METHODS

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Patients with a hip fracture treated with cephalomedullary nailing or hemiarthroplasty (CPT codes 27245 or 27236).

OUTCOME MEASURES AND COMPARISONS

Adherence to a protocol for FICB, time intervals between emergency department arrival, FICB, and surgery stratified by time of admission.

RESULTS

Three hundred eighty patients were studied (average age 78 years, 70% female). Approximately 53.2% of patients received an FICB, which was less than a predefined acceptable adherence rate of 75% ( P < 0.001). Approximately 5.0% received an FICB within 4 hours and 17.3% within 6 hours from admission. Admission during daylight hours (7 am -7p m ) when compared with evening hours (7 pm -7 am ) was associated with improved timeliness ([8.3% vs. 0% within 4 hours, P < 0.001] [27.5% vs. 2.4% within 6 hours, P < 0.001]). Improved adherence to the protocol was observed over time (odds ratio: 1.0013, 95% confidence interval, 1.0001-1.0025, P = 0.0388).

CONCLUSIONS

FICB implementation was poor but gradually improved over time. Few patients received an FICB promptly, especially during night hours. Overall, this study demonstrates that implementation of an FICB program at a Level I academic trauma center can be difficult; however, many hurdles can be overcome with institutional support and dedication of resources such as staff, space, and additional training.

Effect of different analgesic treatments on the pulmonary function in elderly hip fracture patients: A prospective study

BACKGROUND

To investigate the effect of different analgesic methods on lungs in elderly patients with hip fractures.

METHODS

A prospective study was conducted on 78 elderly hip fracture patients undergoing spinal anesthesia for surgery, where 3 analgesic methods were used: postoperative Patient-controlled intravenous analgesia pump (PCIA) (group I), pre and postoperative PCIA (group II), and preoperative fascia iliaca compartment block (FICB) + postoperative PCIA (group III). The following indicators were monitored at admission (T1), on the day of surgery before anesthesia (T2), and 7 days after surgery (T3): heart rate (HR), respiratory rate (RR), forced expiratory volume during the first second, arterial partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2), C-reactive protein (CRP), and interleukin 6 (IL-6). Pulmonary complications such as pulmonary atelectasis and respiratory insufficiency were analyzed.

RESULTS

The HR, RR, forced expiratory volume during the first second, PaO2, PaCO2, IL-6, and CRP levels at T1 after fracture did not significantly differ among the 3 groups (P > .05). After different analgesic treatments post-admission, all indicators at T2 were significantly higher in group I than in groups II and III (P < .05), while there was no significant difference between groups II and III (P > .05). At T3, there were no significant differences in RR, HR, PaO2, PaCO2, and CRP levels among the groups (P > .05), but IL-6 levels at T3 were significantly higher in group I than in groups II and III (P < .05).

CONCLUSION

The use of effective pain relief during surgery can help protect the lung function of elderly patients with hip fractures. When using PCIA with FICB before surgery, respiratory performance may be better protected compared to using unsustained analgesia. This could be due to a decrease in the levels of inflammatory markers such as CRP and interleukin-6.

Mixed-Model Curriculum for Nerve Block Education in Emergency Medicine Residency

Introduction With the rising opioid epidemic, there has been a push for multimodal pain management within the emergency department. Nerve blocks have been shown to be an effective pain management strategy for many conditions, with improved success when used with ultrasound. However, there is no generally accepted method for teaching residents how to perform nerve blocks. Materials and methods Seventeen residents from a single academic center were enrolled. The residents were surveyed pre-intervention regarding demographics, confidence, and use of nerve blocks. The residents then completed a mixed-model curriculum that included an electronic module (e-module) on three plane nerve blocks and a practice session. Three months later, residents were tested on their ability to independently perform the nerve blocks and resurveyed regarding confidence and use. Results Of the 56 residents in the program, 17 enrolled in the study; 16 participated in the first session, and nine participated in the second session. Each resident had < four ultrasound-guided nerve blocks prior to participation with a slight increase in the total number of nerve blocks after the sessions. Residents were able to perform, on average, 4.8 of seven tasks independently. Residents who completed the study reported feeling more confident in their ability to perform ultrasound-guided nerve blocks (p = 0.01) and to complete associated tasks (p < 0.01). Conclusion This educational model resulted in residents completing the majority of tasks independently with improved confidence in ultrasound-guided nerve blocks. There was only a slight increase in clinically performed blocks.

The comparison of postoperative analgesic efficacy of three-in-one-block versus fascia-iliaca blocks following femoral fracture orthopedics surgical procedures under spinal anesthesia, Gondar, Ethiopia, 2021: A prospective cohort study

INTRODUCTION

Femoral bone fracture is the predominant, lower limb orthopedic surgery that is associated with severe acute and persistent chronic pain that needs better postoperative pain management. Untreated postoperative pain results inability to do physiotherapy resulting in stiffens of joints and immobility. This study aimed to compare the postoperative analgesic efficacy of three-in-one-block versus fascia iliaca block in patients who underwent surgically treated femoral fractured patients under spinal anesthesia.

METHODS

A prospective cohort study was conducted on 110 elective surgically treated femoral fractured orthopedic patients from January to October 2021. Data were entered into epi-data 4.4.2 and imported into a statistical package of social science version 22 for analysis. Shapiro-Wilk normality test was used to check the normality of the data and normally distributed data were analyzed using Student's independent t-test, whereas non-normally distributed variables were analyzed with Mann-Whitney U-test. The comparisons of categorical parameters were analyzed using the chi-square test and Fisher's exact test. Finally p-value < 0.05 was declared to be statistically significant.

RESULT

The median and interquartile range of the postoperative numerical rating scale at rest and on movement was significantly less in three-in-one-block (3IN1B) as compared with fascia-iliaca block (FICB). But at 30 min no significantly different between the two pain management modalities. Moreover, the meantime to seek the first request of analgesia was significantly prolonged in 3IN1B compared with FICB. Regarding the total analgesic consumption, the mean total tramadol consumption was 97. 27 ± 53. 07 and 180 ± 72.96 (p < 0.001) and Diclofenac 53.18 ± 29.28 and 72 ± 43.54 (p < 0. 001) in 3IN1 and FICB, respectively.

CONCLUSION

The present study concludes that three-in-one-block provides more effective analgesia, reduced postoperative analgesic requirements, and prolonged first analgesics requests compared with fascia iliaca block, and Landmark technique fascia-iliaca block (FICB) is an alternative pain management modality in a resource-limited setting.

A point-of-care ultrasound approach to fascia iliaca nerve block in a patient with a hip fracture

According to the Centers for Disease Control and Prevention, hip and femoral neck fractures are common fractures seen in older adults. Lower extremity nerve blocks are a tool available for pain control in these patients. One type of block that can be used in this type of fracture is the fascia iliaca compartment block. Clinicians sometimes do not utilize these blocks despite having been shown to produce better pain relief than a standard regimen of intravenous medications. We present a case of a 76-year-old female patient who had inadequate pain relief from intravenous medications. We illustrate the utilization of a standardized approach to a fascia iliaca compartment block using point-of-care ultrasound in the setting of a femoral neck fracture.

A Comparative Study between Postoperative Analgesia of Fascia Iliaca Compartment Block and Anterior Quadratus Lumborum Block in Proximal Femur Fracture

Elderly patients with various comorbidities are more likely to suffer from proximal femur fractures. It is also a painful fracture, and poor pain management can have serious physiological and psychological consequences, such as acute delirium. Purpose. The aim of this study is to compare the efficacy of ultrasound-guided transmuscular (anterior) quadratus lumborum block (QLB) versus infrainguinal fascia iliaca compartment block (FICB) in proximal femur fractures for postoperative analgesia. Patient-reported pain on the visual analogue scale (VAS), analgesic demand, and ambulation were the key factors. Patients and Methods. This prospective, randomised trial was done after receiving approval from the institute' study ethical committee. In this study, ultrasound-guided infrainguinal fascia iliaca compartment block was compared to ultrasound-guided anterior quadratus lumborum block using 50 ml of bupivacaine 0.25%, with a maximum dose of 2.5 mg/kg at the end of surgery after spinal anaesthesia in 128 patients (64 patients in each group). Nalbuphine was given as rescue analgesia if VAS >3. Our 1st outcome was the first rescue analgesia and total analgesic consumption in the 1st 24 hours; the 2nd outcome was the time patients started to ambulate. Results. Postoperative pain perception was substantially greater in the FICB group starting from 30 min (P value 0.022) till 24 hours (P value <0.001), and they received a considerably larger total narcotic dose (14.1 ± 3.5) than patients in the QLB group (7.9 ± 3.4), P value (<0.001 ∗ ). The time required to achieve first rescue analgesia was much less in the FICB group (8.5 ± 2.2) compared to the QLB group (14.1 ± 4.5), P value (<0.001 ∗ ), and they took much longer to ambulate (22.3 ± 4.8) when compared to the QLB group (20.1 ± 4.6), P value (0.011 ∗ ). Hypotension (1.6%) was detected mainly in the QLB group, whereas poor fascial separation (1.6%) was observed only in the FICB group. There were no significant differences in complications between both the FICB and QLB groups. Conclusion. Patients receiving postoperative anterior QL block for proximal femur fracture demonstrated delayed first rescue analgesia and lower total nalbuphine consumption with early ambulation than patients who received FICB.

Effects of Perioperative Fascia Iliaca Compartment Block on Postoperative Pain and Hip Function in Elderly Patients With Hip Fracture

Purpose

Pain management is a challenging issue in elderly patients with hip fracture. Despite the accepted clinical outcomes following hip surgery, pain and prolonged recovery time are the most difficult consequences associated with the rehabilitation process. The purpose of this study was to evaluate pain relief and functional improvement associated with the Fascia Iliaca Compartment Block (FICB) during the perioperative period of elderly patients with hip fracture.

Patients and methods

This study included 120 elderly patients with hip fracture, who were admitted to our institution between January 2019 and December 2020. The participants were subsequently randomly divided into the routine analgesia (RA) and fascia iliaca compartment block (FICB) groups. Inter-group differences were compared via VAS scores at rest and during movement, Harris hip scores (HHS), presence of complications, adverse events after surgery, and length of hospital stay.

Results

The FICB group VAS scores at rest at 6 hour, 1 and 3 days, and 1 week after surgery were significantly lower than the RA group (P < .05). Moreover, the FICB group VAS scores with movement were markedly lower at 6 hour, 1 and 3 days, as well as 1 and 2 weeks after surgery (P < .05). The HHS of the FICB and RA groups were (53.41±8.63) and (40.02±9.61), respectively, on the seventh day after surgery, and the difference was statistically significant (P < .05). The incidence of postoperative complications and adverse events in the FICB group were not statistically different from the RA group. The average hospital stay of the FICB group was 2.12 days shorter than the RA group, but the difference did not reach statistical significance (P = .13).

Conclusion

FICB provides superior analgesic effect both at rest and with movement, along with rapid short-term recovery of hip function following surgery in elderly patients with hip fracture, without increasing postoperative complications or adverse events.

Fascia iliaca block for hip fractures in the emergency department: meta-analysis with trial sequential analysis

BACKGROUND

Fascia iliaca block (FICB) has been used to reduce pain and its impact on geriatric patients with hip fractures.

OBJECTIVE

We conducted this meta-analysis to investigate the analgesic efficacy of this block in comparison to standard of care (SOC) when performed by non-anesthesiologist in the emergency department.

METHODS

Search on PubMed, SCOPUS, EMBASE, Google Scholar and Cochrane database for randomized and quasi-randomized trials were performed. The primary outcome was to compare pain relief at rest at 2-4 h. The pain relief at various time intervals, reduction in opioid use, the incidence of nausea/ vomiting, delirium and length of hospital stay were the secondary outcomes studied. Trial Sequential Analysis (TSA) was performed for the primary outcome.

RESULTS

Eleven trials comprising 895 patients were included in the meta-analysis. Patients receiving FICB had significant better pain relief at rest at 2-4 h with mean difference of 1.59 (95% CI, 0.59-2.59, p = 0.002) with I² = 96%. However, the certainty of the evidence was low and TSA showed that the sample size could not reach the requisite information size. A significant difference in pain relief at rest and on movement started within 30 min and lasted till 4 h of the block. Use of FICB was associated with a significant reduction in post-procedure parenteral opioid consumption, nausea and vomiting and length of hospital stay.

CONCLUSIONS

FICB is associated with significant pain relief both at rest and on movement lasting up to 4 h as well as a reduction in opioid requirement and associated nausea and vomiting in geriatric patients with hip fracture. However, the quality of evidence is low and additional trials are necessary.

A review of evidence-based clinical practice on fascia iliaca compartment block for lower limb injury

BACKGROUND

The main objective of this study was to resolve fascia iliaca compartment block controversies by putting the currently available evidences applied for knee, femoral shaft, and hip bone injury or related to surgery.

METHODS

The databases PubMed, Cochrane Review, and Google Scholar were searched without regard to language or publication type for fascia iliaca compartment block before December 2020. After eligibility sorting and duplicate removal, a total of 26,609 articles were identified, with 21 of them being included for review.

DISCUSSION

In the emergency department, fascia iliaca compartment block (FICB) has now become the standard of practice. Various evidence suggested that 20-40 ml of local anesthetic was required for an effective block in adult patients.

CONCLUSION

For the knee, femoral bone, and hip region surgery, the fascia iliaca compartment block (FICB) provided better anesthesia quality, reduced systemic morphine consumption, and had fewer complications than epidural anesthesia. Anesthetists and surgical department staff should promote the FICB's benefits by emphasizing its superiority in pain management.

Simple Manual Pressure with Ultrasound-Guided Femoral Nerve Block: A randomized single blind study

PURPOSE

The aim of this study was to investigate the effect of compression on the Visual Analog Scale (VAS) score following the application of 3-in-1 femoral nerve block (FNB), used for pain palliation in patients with hip fractures.

METHODS

This was a randomized controlled trial study on application of pressure versus no pressure following FNB in patients with hip fractures. Their VAS scores were recorded and an ultrasound-guided 3-in-1 FNB was performed as a standardized procedure. After the procedure, patients were randomized into two groups and a weight with 2 kg pressure was applied to the treated area in one group. After 30 min, VAS scores were recorded again. VAS scores of all patients recorded before and after the procedure, and post-procedural VAS scores of pressure-applied and no pressure-applied groups were statistically compared.

RESULTS

34 patients were included in this study with 17 patients falling in the compression group (group C), and the remaining half in the non-compression group (group NC). The pre-procedural mean VAS scores were 9.35 (95% CI; 8.95-9.76)), while the post-procedural mean VAS scores dropped to 2.35 (95% CI; 1.65-3.06) in group C. The pre-procedural mean VAS score was 9.12 (95% CI; 8.64-9.59), while the post-procedural mean VAS score was 5.06 (95% CI; 4.09-6.03) in group NC. When the average reductions in VAS score following the procedure were compared, the mean difference between the two groups was calculated to be 2.94 (95% CI; 1.69-4.19) which favours group C. This difference was statistically significant (p < 0.001).

CONCLUSION

Our study shows that, the application of simple compression after 3-in-1 FNB in patients with hip fractures provides a significant reduction in VAS scores.

Regional Nerve Block Decreases the Incidence of Postoperative Delirium in Elderly Hip Fracture

Postoperative delirium is common in elderly patients with hip fracture. Pain is a major risk factor for delirium, and regional nerve blocks (RNBs) effectively control pain in hip fractures. This study aimed to evaluate the effect of RNB on delirium after hip surgery in elderly patients. This retrospective comparative study was performed in a single institution, and the data were collected from medical records between March 2018 and April 2021. Patients aged ≥60 years who underwent proximal femoral fracture surgery were included, while those with previous psychiatric illness and cognitive impairment were excluded. Two hundred and fifty-two patients were enrolled and divided into an RNB or a control group according to RNB use. Delirium was assessed as the primary outcome and postoperative pain score, pain medication consumption, and rehabilitation assessment as the secondary outcomes. Between the RNB (n = 129) and control groups (n = 123), there was no significant difference in the baseline characteristics. The overall incidence of delirium was 21%; the rate was lower in the RNB group than in the control group (15 vs. 27%, respectively, p = 0.027). The average pain score at 6 h postoperatively was lower in the RNB group than in the control group (2.8 ± 1.5 vs. 3.3 ± 1.6, respectively, p = 0.030). There was no significant difference in the pain score at 12, 24, and 48 h postoperatively, amount of opioids consumed for 2 postoperative days, and time from injury to wheelchair ambulation. We recommend RNB as a standard procedure for elderly patients with hip fracture due to lower delirium incidence and more effective analgesia in the early postoperative period.

Point-of-care ultrasound-guided regional anaesthesia in older ED patients with hip fractures: a study to test the feasibility of a training programme and time needed to complete nerve blocks by ED physicians after training

OBJECTIVES

Point-of-care ultrasound-guided regional anaesthesia (POCUS-GRA) provides safe, rapid analgesia for older people with hip fractures but is rarely performed in the emergency department (ED). Self-perceived inadequate training and time to perform POCUS-GRA are the two most important barriers. Our objective is to assess the feasibility of a proposed multicentre, stepped-wedge cluster randomised clinical trial (RCT) to assess the impact of a knowledge-to-practice (KTP) intervention on delirium.

DESIGN

Open-label feasibility study.

SETTING

An academic tertiary care Canadian ED (annual visits 60 000).

PARTICIPANTS

Emergency physicians working at least one ED shift per week, excluding those already performing POCUS-GRA more than four times per year.

INTERVENTION

A KTP intervention, including 2-hour structured training sessions with procedure bundle and email reminders.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary feasibility outcome is the proportion of eligible physicians that completed training and subsequently performed POCUS-GRA. Secondary outcome is the time needed to complete POCUS-GRA. We also test the feasibility of the enrolment, consent and randomisation processes for the future stepped-wedge cluster RCT (NCT02892968).

RESULTS

Of 36 emergency physicians, 4 (12%) were excluded or declined participation. All remaining 32 emergency physicians completed training and 31 subsequently treated at least one eligible patient. Collectively, 27/31 (87.1%) performed 102 POCUS-GRA blocks (range 1-20 blocks per physician). The median (IQR) time to perform blocks was 15 (10-20) min, and reduction in pain was 6/10 (3-7) following POCUS-GRA. There were no reported complications.

CONCLUSION

Our KTP intervention, consent process and randomisation were feasible. The time to perform POCUS-GRA rarely exceeded 30 min, Our findings reinforce the existing data on the safety and effectiveness of POCUS-GRA, mitigate perceived barriers to more widespread adoption and demonstrate the feasibility of trialling this intervention for the proposed stepped-wedge cluster RCT.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov #02892968.

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.

Implementing a Geriatric Fracture Program in a Mixed Practice Environment Reduces Total Cost and Length of Stay

Introduction:

Geriatric-orthopaedic co-management models can improve patient outcomes. However, prior reports have been at large academic centers with “closed” systems and an inpatient geriatric service. Here we describe a Geriatric Fracture Program (GFP) in a mixed practice “pluralistic” environment that includes employed academic faculty, private practice physicians, and multiple private hospitalist groups. We hypothesized GFP enrollment would reduce length of stay (LOS), time to surgery (TTS), and total hospital costs compared to non-GFP patients.

Materials and Methods:

A multidisciplinary team was created around a geriatric Nurse Practitioner (NP) and consulting geriatrician. Standardized geriatric focused training programs and electronic tools were developed based on best practice guidelines. Fracture patients >65 years old were prospectively enrolled from July 2018 – June 2019. A trained biostatistician performed all statistical analyses. A p < 0.05 was considered significant.

Results:

564 operative and nonoperative fractures in patients over 65 were prospectively followed with 153 (27%) enrolled in the GFP and 411 (73%) admitted to other hospitalists or their primary care provider (non-GFP). Patients enrolled in the GFP had a significantly shorter median LOS of 4 days, compared to 5 days in non-GFP patients (P < 0.001). There was a strong trend towards a shorter median TTS in the GFP group (21.5 hours v 25 hours, p = 0.066). Mean total costs were significantly lower in the GFP group ($25,323 v $29085, p = 0.022)

Discussion:

Our data shows that a geriatric-orthopaedic co-management model can be successfully implemented without an inpatient geriatric service, utilizing the pre-existing resources in a complex environment. The program can be expanded to include additional groups to improve care for entire geriatric fracture population with significant anticipated cost savings.

Conclusions:

With close multidisciplinary team work, a successful geriatric-orthopaedic comanagement model for geriatric fractures can be implemented in even a mixed practice environment without an inpatient geriatrics service.

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.

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.

Combination of post-fascia iliaca compartment block and dexmedetomidine in pain and inflammation control after total hip arthroplasty for elder patients: a randomized control study

Objective

This study aims to investigate the efficiency of fascia iliaca compartment block (FICB) combined with dexmedetomidine (DEX) in postoperative and inflammation management for elder patients after total hip arthroplasty.

Methods

The present randomized controlled study included a total of 119 elder patients who received total hip arthroplasty in our hospital from March 2016 to December 2018. These patients were divided into three groups: control group, patients received routine general anesthesia; FICB group, patients received additional FICB after surgery; and combined group, patients received both pre-treatment of DEX and post-treatment of fascia iliaca compartment block. The serum levels of interleukin (IL)-1β, IL-6, and C-reactive protein (CRP) were measured by ELISA. The visual analog scale (VAS) score was measured at 12, 24, 48, and 72 h after surgery, and the patient-controlled intravenous analgesia (PCIA) pressing time within 48 h after surgery was also recorded. The Pittsburgh sleep quality index (PSQI) was used to measure the sleep quality before and at 1 month after surgery.

Results

The VAS scores were significantly lower in patients in the combined group, when compared with the other two groups, at 12, 24, 48, and 72 h after surgery. In addition, the VAS scores at all time points were significantly lower in the FICB group than the control group. The PCIA pressing times were also remarkably lower in the combined group. At 4, 24, 48, and 72 h after surgery, the serum levels of these inflammatory factors were the lowest in the combined group, and the PSQI scores were significantly lower in the combined group, when compared with the other two groups, while the control group had the highest PSQI scores among the three groups. There was no severe side effects and significant difference observed.

Conclusion

FICB combined with DEX reduced the postoperative pain, improved the sleep condition, and decreased the serum levels of inflammatory factors after total hip arthroplasty.

Traumatic Injuries of the Pelvis

Traumatic injuries of the hip and pelvis are commonly encountered in the emergency department. This article equips all emergency medicine practitioners with the knowledge to expertly diagnose, treat, and disposition these patients. Pelvic fractures occurring in young patients tend to be associated with high-energy mechanisms and polytrauma. Pelvic and hip fractures in the elderly are often a result of benign trauma but are associated with significant morbidity and mortality.

Implementing Regional Nerve Blocks in Hip Fracture Programs: A Review of Regional Nerve Blocks, Protocols in the Literature, and the Current Protocol at The Queen's Medical Center in Honolulu, HI

Hip fractures are a common cause of acute pain in elderly patients. However, pain may be undertreated due medical comorbidities. Strong evidence supports the use of regional nerve blocks to reduce preoperative pain after hip fracture. Despite recommendations for their use, regional nerve blocks may not be in widespread practice in the United States. To help promote the addition of regional nerve blocks into hip fracture protocols, this paper will provide an overview of two commonly used regional nerve blocks for hip fracture (fascia iliaca compartment block and femoral nerve block), review the regional nerve block protocols presented in 12 studies, and present the detailed protocol currently in use at The Queen's Medical Center in Honolulu, HI.

Comparison of the postoperative analgesic efficacies of intravenous acetaminophen and fascia iliaca compartment block in hip fracture surgery: A randomised controlled trial

BACKGROUND

Managing pain during movement after hip fracture surgery is important for achieving earlier hip mobilisation and for preventing postoperative complications. In the present study, we tested the hypothesis that the fascia iliaca compartment block (FICB) would improve postoperative pain on movement compared with intravenous acetaminophen.

METHODS

In this prospective, randomised, controlled, parallel trial, patients were assigned to either the intravenous acetaminophen or the ultrasound-guided FICB group. Visual analog scale (VAS) pain scores were evaluated at 6, 9, 12, 18, 24 h, 2 days, and 7 days postoperatively. The primary outcome was VAS scores on movement at 24 h after surgery. The secondary outcomes were VAS scores on movement at the other time points, VAS scores at rest, the total number of rescue analgesics required and incidence of delirium during the first 24 h postoperatively, potential drug or block-related complications, and the time to first standing.

RESULTS

VAS scores on movement at 24 h after surgery were significantly lower in the FICB group than in the intravenous acetaminophen group [median (the 25th to 75th percentiles), 20 (10-30) vs 40 (30-53); P < 0.01]. The VAS scores on movement at any other time point and the scores at rest at 12 h after surgery were also significantly lower in the FICB group than in the intravenous acetaminophen group. The two groups did not differ in terms of the total number of rescue analgesics required or the incidence of delirium during the first 24 h postoperatively; complications; or the time to first standing.

CONCLUSIONS

FICB improved postoperative pain on movement compared with intravenous acetaminophen without increasing the complication rate. However, the total number of rescue analgesics required and the time to first standing were not significantly different between the two groups.

Fascia iliaca block in the emergency department for hip fracture: a randomized, controlled, double-blind trial

Background

Hip fracture causes moderate to severe pain and while fascia iliaca block has been reported to provide analgesic benefit, most previous trials were unblinded, with subsequent high risks of performance, selection and detection biases. In this randomized, control double-blind trial, we tested the hypothesis that a fascia iliaca block provides effective analgesia for patients suffering from hip fracture.

Methods

Thirty ASA I-III hip fracture patients over 70 years old, who received prehospital morphine, were randomized to receive either a fascia iliaca block using 30 ml of bupivacaine 0.5% with epinephrine 1:200,000 or a sham injection with normal saline. The fascia iliaca block was administered by emergency medicine physicians trained to perform an anatomic landmark-based technique. The primary outcome was the comparison between groups of the longitudinal pain score profiles at rest over the first 45 min following the procedure (numeric rating scale, 0–10). Secondary outcomes included the longitudinal pain score profiles on movement and the comparison over 4 h, 8 h, 12 h, and 24 h after the procedure, along with cumulative intravenous morphine consumption at 24 h.

Results

At baseline, the fascia iliaca group had a lower mean pain score than the sham injection group, both at rest (difference = − 0.9, 95%CI [− 2.4, 0.5]) and on movement (difference = − 0.9, 95%CI [− 2.7; 0.9]). These differences remained 45 min after the procedure and the two longitudinal pain score profiles were parallel both for patients at rest and on movement (test of parallelism for patients at rest p = 0.53 and on movement p = 0.45). The same parallel change in pain scores over time was observed over 24 h of follow-up (test of parallelism for patients at rest p = 0.82 and on movement p = 0.12). These results were confirmed after adjustment for gender, ASA score, and cumulative sums of intravenous morphine received pre-procedure and during-follow-up. In addition, there was no difference between the two groups in total cumulative intravenous morphine consumption at 24 h.

Conclusion

Fascia iliaca block following anatomic landmarks may not provide supplementary analgesia for patients suffering from hip fracture, when low pain scores are reported after prehospital morphine. Additional larger trials will help reach definitive conclusion.

Trial registration number

Clinicaltrials.gov – NCT02433548. The study was registered retrospectively.

Rapid Analgesia for Prehospital hip Disruption (RAPID): findings from a randomised feasibility study

Background

In managing hip fracture, effective pain relief before admission to hospital is difficult without risking side effects. Although emergency departments routinely use fascia iliaca compartment block (FICB), there has been little evaluation of its use by paramedics before hospital admission. We aimed to assess whether a multi-centre randomised trial to evaluate FICB was feasible.

Methods

Volunteer paramedics used scratchcards to allocate patients with hip fracture at random between FICB and pain relief as usual. Primary outcomes were mortality and quality of life. We also measured adverse events, costs, final diagnosis, length of stay in hospital, pain scores and quality of care and collected qualitative data about acceptability to patients in interviews, and paramedics in focus groups. We pre-specified criteria for deciding whether to progress to a fully powered trial based on the recruitment of paramedics and patients, delivery of FICB, retrieval of outcome data, safety, acceptability, and diagnostic accuracy of hip fracture.

Results

We effectively met all progression criteria: we recruited 19 paramedics who randomly allocated 71 patients between trial arms between 28 June 2016 and 31 July 2017; 57 (31 experimental arm, 26 usual care arm, 80% overall) retrospectively consented to follow-up. Just over half (17/31) of experimental participants received FICB; all others had contraindications, including nine taking anticoagulants. Four of the 31 participants assigned FICB and six of the 26 assigned usual care died within 6 months of hospital admission. Serious adverse events were also similar: 3/35 experimental versus 4/36 in usual care. Paramedics’ recognition of hip fracture had sensitivity of 49/64 (77%) with a positive predictive value of 46/57 (81%). We received quality of life questionnaires for 30 of 49 patients (61%) at 1 month and 12 of 17 (71%) at 6 months. Patient satisfaction was similar: experimental mean 3.4 (n = 20) versus 3.5 (n = 13) for usual care.

Conclusions

RAPID met all progression criteria within reasonable limits. As equipoise remains, we plan to undertake a fully powered multi-centre trial to test clinical and cost effectiveness of paramedic-administered FICB at the scene of hip fracture.

Trial registration

ISRCTN 60065373 sought 5 November 2015.

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0454-1) contains supplementary material, which is available to authorized users.

Ultrasound guided supra-inguinal Fascia Iliaca Compartment Blocks in hip fracture patients: An alternative technique

INTRODUCTION

In the Emergency Department, regional anesthesia is increasingly used in elderly patients with hip fractures. An example is a Fascia Iliaca Compartment Block (FICB). Traditionally, this block is administered below the inguinal ligament. There is no Emergency Department data regarding effectivity of an alternative, more cranial approach above the inguinal ligament. The objective was to determine analgesic effects of an ultrasound-guided supra-inguinal FICB in hip fracture patients in the Emergency Department.

METHODS

This case series included all Emergency Department hip fracture patients who were treated with a supra-inguinal FICB during a period of 10 months. All data were recorded prospectively. Primary study outcome was decrease in Numerical Rating Scale (NRS) pain scores 60 min after the FICB. Secondary outcomes included the proportion of patients achieving 1.5 NRS points decrease at 60 min; NRS differences at 30 and 120 min compared to baseline; need for additional analgesia and occurrence of adverse events.

RESULTS

A total of 22 patients were included in the study. At 60 min median NRS pain scores decreased from 6.0 to 3.0 (p < 0.001). Of all patients, a total of 59% achieved a decrease in 1.5 NRS points after 60 min. Median pain scores at 30 and 120 min were 4.0 (Interquartile Range (IQR) 2.0-5.0) and 2.5 (IQR 0.8-3.0). Seven patients (31.8%) required additional opioid analgesia after the FICB. No adverse events were recorded.

CONCLUSION

An ultrasound-guided supra-inguinal FICB decreases NRS pain scores in hip fracture patients both clinically relevant and statistically significantly after 60 min.

CLINICAL TRIAL REGISTRATION

The study was registered in the ISRCTN database (ISRCTN74920258).

Pre-operative pain management with nerve block in patients with hip fractures: a randomized, controlled trial

INTRODUCTION

Pain management in patients with hip fractures is a major challenge for emergency care. The objective of this study was to evaluate whether the supplementation of pre-operative analgesia with low-dose fascia iliaca compartment block (FICB) compared with placebo would improve pain relief in patients with hip fractures.

METHODS

A double-blind, randomized, controlled trial was conducted on 127 patients. At hospital admission, a low-dose FICB was administered to patients with hip fractures as a supplement to regular pre-operative analgesia. Patients with and without cognitive impairment were included. The instruments used were a visual analogue scale (VAS), a numerical rating scale and a tool for behavior related pain assessment. The primary endpoint was the change in reported pain on movement from hospital admission to two hours after FICB.

RESULTS

The intervention group showed improved pain management by mean VAS score for pain on movement compared with the control group (p = 0.002).

CONCLUSIONS

Our results support the use of low-dose FICB as a pain-relieving adjuvant to other analgesics when administered to patients with a hip fracture.

Fascia Iliaca Compartment Block Efficacy in Resource-poor Emergency Departments

Introduction

Although the fascia iliaca compartment block (FICB) seems to be an ideal technique for femoral neck and shaft fractures occurring in resource-poor settings, it has been unclear how effective it is when used by emergency physicians (EP) with little training in the technique, using equipment, medications and methods that differ from those commonly available in developed countries. This series was designed to demonstrate that EPs in a resource-poor setting can provide effective analgesia for femur fractures with anatomic landmark-guided FICBs, clinician-compounded lidocaine-epinephrine (1:100,000), and a standard injection needle.

Methods

Over a three-month period, patients ≥12 years old presenting to the emergency department with hip or femur fractures and a Likert visual analogue scale >4 had an EP-administered FICB. EPs used a standard intramuscular needle and a lidocaine-epinephrine solution they compounded at the bedside and located the injection site using only anatomic landmarks. EPs evaluated the patient’s pain level at 30 minutes and at two hours post-FICB. We also reviewed articles since 2016 that describe the FICB.

Results

We enrolled a non-consecutive sample of 10 patients in the case series. Five had femoral neck (hip) fractures and five had femoral shaft fractures. All patients had a reduction in their pain levels after the FICB. On average, the block took effect about three minutes after injection. At 30 minutes all patients reported clinically meaningful pain reduction. The analgesic effect of the compounded agent lasted approximately 200 minutes. No adverse effects were reported. No published journal articles about FICB since 2016 were from resource-poor settings, and only one was from a developing country.

Conclusion

This series suggests that the FICB is effective even when performed with the minimal materials that are usually available in resource-poor settings. Methods such as this, which use simplified clinical tests and techniques applicable in resource-poor settings, can assist global emergency medicine (EM). We can assist global EM by similarly finding methods to simplify useful clinical tests and techniques that can be used in resource-poor settings.

A Robust Approach to Implementing Fascia Iliaca Compartment Nerve Blocks in Hip Fracture Patients

BACKGROUND

A clear imperative exists to optimize the preoperative pain management of hip fracture patients. Increasingly, fascia iliaca compartment blocks (FICBs) are being effectively utilized as an adjunct to oral analgesia in the emergency department.

PURPOSE

We investigated the feasibility, safety, and delivery rate when junior doctors and specialist nurses are trained in FICBs delivery, alongside the introduction of a step-by-step proforma.

METHODS

We conducted a retrospective study of hip fractures patients presenting preinterventions (n = 138) between October and December 2014 and postinterventions (n = 246) between April and August 2015. Outcomes analyzed included delivery frequency, anesthetic dosages used, and procedure documentation.

RESULTS

Preintervention, FICB was performed in 40% (n = 51) of eligible patients, with an improvement to 72% (n = 160) postintervention. Postinterventions, 98% of FICBs were performed with the anesthetic dose recommended-a prescription between 75 and 100 mg of 0.25% levobupivacaine. No adverse patient outcomes, relating to the interventions implemented, were noted during the study period.

CONCLUSION

Delivery of FICB by junior doctors and specialist nurses in the emergency department is feasible, safe, and improves the proportion of patients receiving blocks.

Ultrasound-guided continuous fascia iliaca compartment block for pre-operative pain control in very elderly patients with hip fracture: A randomized controlled trial

The present study presented the results of a prospective, randomized controlled trial. The present study enrolled 98 very elderly patients with hip fractures, complicated with at least one cardiovascular, neurological or pulmonary disease, of whom 10 patients were excluded. A total of 88 patients were randomly assigned into 2 groups: i) The control group, receiving traditional analgesia including 50 mg Tramadol and 500 mg paracetamol orally three times a day from admission to surgery; and ii) the study group, receiving ultrasound-guided continuous fascia iliaca compartment block (CFICB), a single 50 ml 0.4% ropivacaine injection with continuous infusion of 0.2% ropivacaine at a dose of 5 ml/h from admission to surgery. The primary outcome measure of pain relief or pain intensity was assessed preoperatively and up to 48 h postoperatively using a visual analog scale (VAS). The results of the present study indicated that in the preoperative period, in the morning of the day of surgery, the VAS pain at rest scores were lower in the study group compared with the control group (P=0.023). The VAS passive movement scores of the study group were also significantly lower compared with the control group 1 h following analgesia at the time of admission (P<0.05) and in the morning of the day of surgery (P<0.05). Scores for patients' satisfaction with the analgesic regimen in the preoperative period were greater in the study group compared with the control group (P<0.001). There was no difference in analgesia-associated side effects between groups. Duration of hospital stay of patients in the control group was significantly longer compared with the study group (P=0.001). Patients in the study group were less likely to have increased complications compared with patients in the control group over the N2-N4 period (from preoperative period to after surgery; P=0.016). The present study concluded that ultrasound guided CFICB was an effective method of providing analgesia for very elderly (≥80 years old) with hip fracture.

Comparative Study for Evaluating Efficacy of Fascia Iliaca Compartment Block for Alleviating Pain of Positioning for Spinal Anesthesia in Patients with Hip and Proximal Femur Fractures

BACKGROUND

Patient positioning for performing spinal blockade causes severe pain in hip and femur fracture. Adequate pain relief before administrating spinal blockade will increase patient's cooperation. This study was done to assess analgesic effect of fascia iliaca compartment block (FICB) for positioning for spinal anesthesia.

MATERIALS AND METHODS

This was a randomized, double blind, controlled prospective study that included 100 patients of the American Society of Anesthesiologists physical statuses I to III, of either sex, between 30 and 90 years, posted for hip or proximal femoral surgery, with visual analogue scale (VAS) >3 in preoperative period. The two groups were assigned randomly. In Group 1, FICB was given half an hour before shifting the patients in operation theater with 30 ml of 0.25% ropivacaine, and in Group 2, sham block was given with 30 ml normal saline. Each group included 50 patients. Thirty minutes after FICB, spinal anesthesia was given and patients' vitals were monitored before and after block, at the time of positioning for spinal anesthesia, intraoperative and postoperative periods.

RESULTS

In Group 1, mean VAS before FICB was 8.02 which reduced to 2.28, which is statistically significant (P = 7.8813E-50), whereas in Group 2, mean VAS before sham block was 7.98 which reduced to 7.90, which is statistically nonsignificant (P = 0.6694). Mean total duration of analgesia in Group 1 was 428.3 min after spinal anesthesia, whereas in Group 2, mean total duration of analgesia was 240.1 min.

CONCLUSION

FICB effectively provides analgesia for positioning for spinal anesthesia to patients in hip and proximal femur surgeries. It also provides analgesia in postoperative period without having significant alteration in the hemodynamic profile of patients.

Nerve Blocks in the Geriatric Patient With Hip Fracture: A Review of the Current Literature and Relevant Neuroanatomy

Introduction

Hip fracture is a common occurrence in the elderly population with high morbidity and mortality due to postoperative pain and opioid use. The goal of this article is to review the current literature on the neuroanatomy of the hip and the use of localized nerve block in controlling hip fracture pain.

Methods

A thorough search of MEDLINE/PubMed, Embase, and the Cochrane Database of Systematic Reviews was conducted using the search terms "hip fracture" and "fascia iliaca block (FICB)." An additional search was conducted utilizing multiple search terms including "hip fracture," "greater trochanter," "femur," "hip," "anatomy," "neuroanatomical," and "anatomic." Each search result was investigated for cadaveric studies on the innervation of the trochanteric region.

Results

Twenty-five clinical studies examining the use of FICBs in hip fracture patients were identified. These studies show that FICB is safe and effective in controlling perioperative pain. Additionally, FICB has been shown to decrease opioid requirement and opioid-related side effects. Neuroanatomical studies show that the hip capsule is innervated by contributions from the femoral, obturator, sciatic, and superior gluteal nerves. Imaging studies suggest that FICB anesthetizes these branches through localized spread along the fascia iliaca plane. Cadaveric evidence suggests that the greater trochanter region is directly innervated by a single branch from the femoral nerve.

Discussion

The proven efficacy of nerve blocks and their anatomic basis is encouraging to both the anesthesiologist and orthopedic surgeon. Their routine use in the hip fracture setting may improve patient outcomes, given the unacceptably high morbidity and mortality associated with opioid use.

Conclusions

Localized nerve blocks, specifically FICB, have been shown to be safe and effective in managing acute hip fracture pain in geriatric patients, leading to decreased opioid use. Knowledge of the hip neuroanatomy may help guide future development of hip fracture pain blockade.

The Importance of Optimizing Acute Pain in the Orthopedic Trauma Patient

Postoperative pain control is a highly studied topic because of its significant effect on costs, hospital course, and, most importantly, patient satisfaction. Opioid use has been the "status quo" of postoperative pain management but prolongs hospital stays and increases complications. Optimizing acute pain management in patients with orthopedic trauma is important and can translate into significant positive physiologic and financial outcomes. Although multiple viable examples of optimizing acute pain management in the literature demonstrate outcome improvements, implementation has not been widespread. Significant outcome success will depend more on systemwide implementation than a specific regimen for postoperative pain control.

Fascia iliaca block for pain control in hip fracture patients

INTRODUCTION

Pain treatment for patients with hip fracture has been based on the use of nonsteroidal anti-inflammatories and opioid derived drugs. These medications have been associated with multiple adverse effects. Fascia iliaca block is a recent pain management alternative for these patients. The objective of this study was to evaluate the effectiveness of fascia iliaca block performed in the emergency room (ER) for patients over 65years of age with hip fracture.

MATERIALS AND METHODS

A cohort of 216 patients, from January to December 2016, was studied prospectively. Analyzed variables were: pain upon arrival at ER, pain after fascia iliaca block, need for rescue medication, protocol compliance, delay in analgesia administration and delay for surgery.

RESULTS

Differences between visual analogue scale (VAS), before and after the fascia iliaca block, were statistically significant (P<.001). Pre-block VAS recorded was 6.16 (SD=2.82). The mean VAS reduction after the block was 2.99 (95%CI: 2.45-3.53%). Twenty-six percent of patients required morphine as rescue medication in the first 8hours after diagnosis. Compliance with protocol administration was of 84%. Fascia iliaca block was performed in a mean time of 16minutes (SD=10.33) after diagnosis. The median delay for surgery was 1 day (RIQ 25-75%: 1-2).

CONCLUSION

Fascia iliaca block is a reproducible, safe and effective technique for pain management. It is a keystone in pain treatment for patients with a proximal femur fracture at our institution. Other objectives in our pain management protocol include early analgesia administration and reduction of time to surgery.

Emergency Department Pain Management Following Implementation of a Geriatric Hip Fracture Program

INTRODUCTION

Over 300,000 patients in the United States sustain low-trauma fragility hip fractures annually. Multidisciplinary geriatric fracture programs (GFP) including early, multimodal pain management reduce morbidity and mortality. Our overall goal was to determine the effects of a GFP on the emergency department (ED) pain management of geriatric fragility hip fractures.

METHODS

We performed a retrospective study including patients age ≥65 years with fragility hip fractures two years before and two years after the implementation of the GFP. Outcomes were time to (any) first analgesic, use of acetaminophen and fascia iliaca compartment block (FICB) in the ED, and amount of opioid medication administered in the first 24 hours. We used permutation tests to evaluate differences in ED pain management following GFP implementation.

RESULTS

We studied 131 patients in the pre-GFP period and 177 patients in the post-GFP period. In the post-GFP period, more patients received FICB (6% vs. 60%; difference 54%, 95% confidence interval [CI] 45-63%; p<0.001) and acetaminophen (10% vs. 51%; difference 41%, 95% CI 32-51%; p<0.001) in the ED. Patients in the post-GFP period also had a shorter time to first analgesic (103 vs. 93 minutes; p=0.04) and received fewer morphine equivalents in the first 24 hours (15mg vs. 10mg, p<0.001) than patients in the pre-GFP period.

CONCLUSION

Implementation of a GFP was associated with improved ED pain management for geriatric patients with fragility hip fractures. Future studies should evaluate the effects of these changes in pain management on longer-term outcomes.

Effect of admission fascia iliaca compartment blocks on post-operative abbreviated mental test scores in elderly fractured neck of femur patients: a retrospective cohort study

Background

Post-operative cognitive impairment is common in elderly patients following surgery for hip fracture, with undertreated pain being an important etiological factor. Non-opioid based analgesic techniques, such as nerve blocks, may help reduce the risk of cognitive complications. The aim of this study was to investigate whether receiving a fascia iliaca compartment block (FICB) as part of a pre-operative analgesic regime increased the odds of high post-operative abbreviated mental test scores (AMTS) when compared with conventional analgesia without a nerve block.

Methods

A retrospective data analysis of a cohort of 959 patients, aged ≥ 65 years with a diagnosis of hip fracture and admitted to a single hospital over a two-year period was performed. A standardized analgesic regime was used on all patients, and 541/959 (56.4%) of included patients received a FICB. Provision of the FICB was primarily determined by availability of an anesthetist, rather than by patient status and condition. Post-operative cognitive ordinal outcomes were defined by AMTS severity as high (score of ≥9/10), moderate, (score of 7–8) and low (score of ≤6). A multivariable ordinal logistic regression analysis was performed on patient status and clinical care factors, including admission AMTS, age, gender, source of admission, time to surgery, type of anesthesia and ASA score.

Results

Admission FICB was associated with higher adjusted odds for a high AMTS (score of ≥9) relative to lower AMTS (score of ≤8) than conventional analgesia only (OR = 1.80, 95% CI 1.27–2.54; p = 0.001). Increasing age, lower AMTS on admission to hospital, and being admitted from a residential or nursing home were associated with worse cognitive outcomes. Mode of anesthesia or surgery did not significantly influence post-operative AMTS.

Conclusion

Post-operative AMTS is influenced by pre-operative analgesic regimes in elderly patients with hip fracture. Provision of a FICB to patients on arrival to hospital may improve early post-operative cognitive performance in this population.

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.

Pre-operative lumbar plexus block provides superior post-operative analgesia when compared with fascia iliaca block or general anesthesia alone in hip arthroscopy

The objective of this study is to retrospectively examine the effects of pre-operative fascia iliaca (FI) and lumbar plexus (LPB) nerve blocks on post-operative pain and secondary post-operative variables following arthroscopic surgery of the hip. Subjects undergoing arthroscopic surgery of the hip received one of three pre-operative anesthetic techniques; general anesthesia only, general anesthesia with FI or general anesthesia with LPB. Patient reported pain scores (0–10) were recorded at 0, 30, 60, 90 and 120 min after admission to the post-anesthesia care unit (PACU). Secondary variables examined include time spent in the PACU, morphine equivalent administered, presence of nausea, persistent numbness, parasthesia, weakness, increased narcotic usage for rebound pain, ED visits and hospital admissions. The mean pain scores over all time points were significantly lower in the LPB group (2.38) than the FI group (4.08, P < 0.001) and the Gen group (3.55, P < 0.001). Patients receiving a lumbar plexus block exhibited significantly decreased pain at t = 0 (P = 0.019), t = 30 (P = 0.038), t = 60 (P = 0.013), t = 90 (P = 0.017) and t = 120 (P = 0.001) after admission to PACU. The FI group showed no improvement in any post-operative variable when compared with general anesthesia alone. There was no difference in the time to discharge or in morphine equivalent administered between groups. One patient receiving a lumbar plexus block experienced a seizure lasting about 10 s. However, there were no medium or long-term complications. Lumbar plexus block administered in concert with general anesthesia provides clinically important and statistically significant post-operative pain relief when compared with general anesthesia alone or general anesthesia plus fascia iliaca block.

Perioperative pain management in hip arthroscopy; what options are there?

Hip arthroscopy is a fast growing orthopedic field of expertise. As in any field of surgery adequate postoperative pain management regimes are of utmost importance. The purpose of this review is to provide an overview of current knowledge on anesthetic options for perioperative pain management for hip arthroscopy. We searched the Pubmed/Medline and Embase database for literature and included 10 studies for our analysis. Because of the variety of pain scales and different ways of measured pain no meta-analysis could be performed and a descriptive review is performed. There are several types of pain regimens that can mostly be divided in two groups: local anesthetics and nerve blocks. Included studies show a rather large variation in reported visual analogue scale scores, post anesthesia care unit admission time and opioid usage. There are several anesthetic options available for hip arthroscopy. Different studies use different dosages, anesthetic regimens and different protocols; this partly explains the differences between studies with similar techniques. Peripheral nerve blocks seems promising but regarding current literature no clear recommendation can be made about what the best perioperative pain management option is, an overview of all reported techniques is given.

Analgesia in hip fractures. Do fascia-iliac blocks make any difference?

Despite recent national advances in the care for the hip fracture patient, significant morbidity and mortality persists. Some of this morbidity is attributable to the analgesia provided in the hospital setting. The National Institute of Health and Care Excellence and the Association of Anaesthetists of Great Britain and Ireland recommend the use of simple oral analgesia including opioids, with fascia-iliac blocks (FIB) used as an adjunct. Literature review reveals a paucity of evidence on this.

The aim of this project was to evaluate the proportion of patients receiving a fascia-iliac block prior to operative intervention. A secondary aim was to evaluate the efficacy of these blocks through analysis of pre and post-operative opioid usage, post-operative delirium, time to bowel opening, and naloxone use.

Patients who received a fascia-iliac block received significantly less post-operative and total analgesia (p=0.04, p=0.03), had lower rates of delirium (p=0.03) and those patients which were discharged directly home had a shorter inpatient stay (p=0.03). No patients who received a fascia-iliac block (FIB) needed naloxone to reverse opioid toxicity, whilst two without fascia-iliac block did. The results of the project eventually led to the introduction of a hip fracture care pathway which incorporates a single shot fascia-iliac block for all patients who are eligible. Within a two year study period, compliance with fascia-iliac blocks improved from 54% to 90%.

Our experience shows a great improvement in compliance with fascia-iliac blocks in the pre-operative period. This work has also underpinned the introduction of a new hip fracture care pathway ultimately to better patient care and outcomes.

Single Fascia Iliaca Compartment Block is Safe and Effective for Emergency Pain Relief in Hip-fracture Patients

Introduction

Currently, it is common practice in the emergency department (ED) for pain relief in hip-fracture patients to administer pain medication, commonly systemic opioids. However, with these pain medications come a high risk of side effects, especially in elderly patients. This study investigated the safety profile and success rate of fascia iliaca compartment block (FICB) in a busy ED. This ED was staffed with emergency physicians (EPs) and residents of varying levels of experience. This study followed patients’ pain levels at various hourly intervals up to eight hours post procedure.

Methods

Between September 2012 and July 2013, we performed a prospective pilot study on hip-fracture patients who were admitted to the ED of a teaching hospital in the Netherlands. These patients were followed and evaluated post FICB for pain relief. Secondary outcome was the use of opioids as rescue medication.

Results

Of the 43 patients in this study, patients overall experienced less pain after the FICB (p=0.04). This reduction in pain was studied in conjunction with the use and non-use of opioids. A clinically meaningful decrease in pain was achieved after 30 minutes in 62% of patients (54% with the use of opioids, 8% without opioids); after 240 minutes in 82% of patients (18% with opioids, 64% without opioids); after 480 minutes in 88% of patients (16% with opioids, 72% without opioids). No adverse events were reported.

Conclusion

In a busy Dutch ED with rotating residents of varying levels of experience, FICB seems to be an efficient, safe and practical method for pain reduction in patients with a hip fracture. Even without the use of opioids, pain reduction was achieved in 64% of patients after four hours and in 72% of patients after eight hours.

Pain relief management following proximal femoral fractures: Options, issues and controversies

The majority of proximal femoral fractures occur in the elderly population. Safe and adequate pain relief is an integral part of the overall management of hip fractures. Inherent difficulties in the assessment of pain in elderly need to be taken into account and unique considerations should be made regarding the effective analgesia due to different elderly physiology, and their response to trauma and subsequent surgery. The pain management should start as soon as possible and special emphasis should be paid to contemporary methods of regional anaesthesia whilst a multimodal approach should be adopted in the perioperative period. The present review summarises the contemporary treatment options and controversies pertaining to the management of pain in elderly patients with proximal femoral fractures.