Ultrasound-guided femoral nerve blocks are not superior to ultrasound-guided fascia iliaca blocks for fractured neck of femur

Effects of posterior lumbar plexus block on anesthesia and sedation in postmenopausal patients with osteoporotic subtrochanteric comminuted fractures

To study the effect of posterior lumbar plexus nerve block on anaesthesia and sedation in postmenopausal patients with osteoporotic subtrochanteric femoral comminuted fractures. The research subjects selected 48 patients with postmenopausal osteoporotic subtrochanteric comminuted fractures who were hospitalized between January 2020 and January 2022, and were allocated to clusters according to the random number TBL approach. The controlling cluster (24 situations) underwent dura mater Under external anesthesia, the test cluster (24 situations) underwent posterior lumbar plexus block, and the block effect, anesthesia effect, sedation effect, hemodynamics, vital signs and reactions of adverse nature were contrasted involving the two clusters. In comparison to the control group, the test group had a longer duration of anesthesia and motor block, higher oxygenation indices but lower ITBVI, GEDVI, and ScrO2 values, lower MAP levels, and lower BIS contraction values at 5, 15, and 30 minutes following anesthesia (P < 0.05). The test group had shorter induction time and block onset time compared to the control group (P < 0.05), and a lower incidence of adverse reactions (16.67% vs. 29.17% in the control group), but the variation was not noTBL (P < 0.05). Posterior lumbar plexus nerve block in postmenopausal patients with osteoporotic subtrochanteric femoral comminuted fractures has a better sedative effect, shortens the induction time of anaesthesia and the onset of block, promotes sTBL haemodynamic indexes and has fewer adverse effects to ensure safety.

Preoperative Fascia Iliaca Blocks Associated With Decreased Opioid Consumption in Femoral Shaft and Distal Femur Fractures

OBJECTIVES

To examine the impact of fascia iliaca (FI) blocks performed in the emergency department on femoral shaft and distal femur fracture patients on opioid consumption, length of stay (LOS), and readmission rate.

METHODS

DESIGN

Prospective cohort study.

SETTING

Community-based Level 1 trauma center.

PATIENT SELECTION CRITERIA

Patients with isolated low-energy femoral shaft or distal femur fractures (OTA/AO 32 and 33) presenting from January 1, 2020, to May 31, 2022, were included.

OUTCOME MEASURES AND COMPARISONS

Opioid consumption, LOS, discharge disposition, and 30-day readmission rate were compared between patients undergoing FI compartment block and not receiving the block.

RESULTS

One hundred thirty-six patients were included. Twenty-four received FI block. Both cohorts were primarily female gender (66.7% and 66.9%, respectively, for the FI block and the no FI block cohort). Most of the FI block cohort had femoral shaft fractures (62.5%), whereas the no FI block cohort had mostly distal femur fractures (56.2%). The mean body mass index, fracture type, and surgical procedure were similar between patients undergoing FI block and not receiving FI block. The FI block group had significantly lower opioid consumption preoperatively [36.1 vs. 55.3 morphine milliequivalents (MMEs), P = 0.030], postoperatively (71.7 vs. 130.6 MMEs, P = 0.041), and over total hospital stay (107.9 vs. 185.9 MMEs) including the mean opioid consumption per day of hospital stay (25.9 vs. 48.4 MMEs, P = 0.003). There was no significant difference in LOS (4.9 vs. 5.0 days, P = 0.900), discharge disposition destination ( P = 0.200), or 30-day readmissions (12.5% vs. 4.5%, P = 0.148) between groups.

CONCLUSIONS

Undergoing FI block in the emergency department was associated with decreased opioid consumption in patients with femoral shaft or distal femur fractures. There was no associated difference in LOS, discharge disposition, or 30-day readmissions.

LEVEL OF EVIDENCE

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

Ultrasound-guided femoral nerve block versus fascia iliaca compartment block for femoral fractures in emergency department: A randomized controlled trial

Aim

Femoral fractures are one of the most debilitating injuries presenting to the emergency departments (EDs). The pain caused by these fractures is typically managed with opioids and adjunctive regional analgesia. These approaches are often associated with adverse side effects. Thus, appropriate alternative methods should be thoroughly investigated. To evaluate ultrasound-guided femoral nerve block (FNB) with ultrasound-guided fascia iliaca compartment block (FICB) in femoral fractures, to determine which provides better analgesia and less opioid requirement.

Methods

This study was a randomized clinical trial performed on adult patients presenting to the ED within 3 h of isolated femoral fracture with initial numerical pain rating scale (NRS-0) score of more than 5. The patients were randomized to receive FNB or FICB. The outcomes were block success rates, pain at 20 (NRS-20) and 60 (NRS-60) min after the end of the procedures, as well as the number and total dose of fentanyl administration during ED stay.

Results

Eighty-seven patients were recruited (40 FNB and 47 FICB). Success rates were 82.5% in FNB and 83.0% in FICB group, with no significant difference between the groups. NRS-20, NRS-60, the number of patients who received supplemental fentanyl, and the total dose of administered fentanyl were significantly lower following FNB. However, the length of the procedure was significantly lower in the FICB group.

Conclusion

Both FNB and FICB are effective in pain reduction for fractures of femur, but FNB provides more pain relief and less need for supplemental fentanyl.

A pilot study evaluating high dose esomeprazole, bismuth subcitrate and amoxicillin for eradicating Helicobacter pylori infection in Iran

BACKGROUND

Helicobacter pylori (H. pylori) is strongly associated with peptic ulcer disease and gastric cancer. We evaluated two triple therapy regimens comprising esomeprazole, high dose bismuth, and different doses of amoxicillin for first-line H. pylori eradication.

MATERIALS AND METHODS

Two hundred patients with dyspepsia and naive H. pylori infection were randomly assigned into two groups (n = 100). Both groups were treated for 14 days similarly with esomeprazole (40 mg, twice daily) and bismuth subcitrate (240 mg, three times daily), but the dose of amoxicillin was varied between Groups A (750 mg) and B (1000 mg) three times daily. Treatment compliance and side effect were evaluated following the therapies and after 8 weeks, a negative test of stool H. pylori antigen confirmed eradication.

RESULTS

The two groups were comparable with respect to sex and age. According to intention to treat analysis, eradication rates were 80% (95% CI: 77.2%-82.8%) and 90% (95% CI: 84.1%-95.9%) in A and B groups, respectively (p = 0.22). Per-protocol eradication rates were 87% (95% CI: 80.4%-93.6%) and 92.8% (95% CI: 87.7%-97.9%), respectively (p = 0.23). Severe adverse effects were 3% and 2%, respectively (p = 0.34).

CONCLUSION

High dose esomeprazole, amoxicillin and bismuth achieved 92.8% cure rates per protocol in a country with a high background rate of resistance. Additional studies are needed to ascertain whether this therapy can be further improved. Until then, it can be recommended as a first-line H. pylori eradication in north of Iran.

An integrative comparative study between ultrasound-guided regional anesthesia versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: A systematic review and meta-analysis

Background

Emergency physicians play a major role in managing patients with hip fractures. The most commonly used pain management option is parenteral opioids. However, parenteral opioids are subjected to several adverse effects. New pain management techniques such as regional anesthesia are used as alternatives to parenteral opioids. Anatomical landmarks were used to administer regional anesthesia; however, ultrasound guidance has shown promising results with regional anesthesia.

Objective

of the Review: The present study compares the efficacy of ultrasound-guided regional anesthesia (USGRA) to parenteral opioids in analgesia of hip fractures patients.

Methods

A literature search for original and relevant articles carried out through six electronic databases, yielded 710 articles which were then assessed using the eligibility criteria resulting in 8 studies eligible for inclusion.

Results

A Meta-analysis of the seven studies showed that ultrasound-guided femoral nerve block was more effective than parenteral opioids in relieving pain. Similarly, meta-analysis of data from two studies shows that US-guided FICB significantly reduced pain scores than parenteral opioids. A subgroup analysis of adverse events showed no significant difference in nausea/vomiting and respiratory complications. However, a subgroup analysis on hypotension showed that the incidence of hypotension was significantly lower in USGRA than parenteral opioids. The present study also revealed that patients in the USGRA group required less frequent rescue analgesia than the patients in the parenteral opioids group.

Conclusion

Results of the present study show that USGRA is superior to parenteral opioids in reducing pain and the need for rescue analgesia in patients with hip fractures.

Pericapsular nerve group block for hip fracture is feasible, safe and effective in the emergency department: A prospective observational comparative cohort study

OBJECTIVES

The pericapsular nerve group (PENG) block was first described for analgesia of hip fracture in 2018. We hypothesised that the PENG block is safe and effective for patients with hip fracture when provided by emergency physicians and trainees in the ED.

METHODS

This was an observational study of routine care. Consecutive patients receiving regional anaesthesia for hip fracture at a single ED were prospectively enrolled. Pain scores were assessed prior to regional anaesthesia then at 15, 30 and 60 min after administration. Maximal reduction in pain scores within 60 min were assessed using the Visual Analogue Scale (at rest and on movement) or the Pain Assessment IN Advanced Dementia tool (at rest). Patients were followed for opioid use for 12 h after regional anaesthesia and adverse events over the duration of admission.

RESULTS

There were 67 eligible patients during the enrolment period, with 52 (78%) prospectively enrolled. Thirty-three received femoral blocks (19 fascia iliaca compartment blocks, 14 femoral nerve blocks) and 19 received a PENG block. Inexperienced providers were able to successfully perform the PENG block. There was no difference in maximum pain score reduction between the groups. There was no difference in adverse effects between groups. Opioid use was similar between the groups. More patients were opioid-free after a PENG block.

CONCLUSIONS

The present study demonstrated that the PENG block can be provided safely and effectively to patients with hip fracture in the ED. On the basis of this pilot study, a larger randomised controlled study should now be designed.

Comparison of Femoral Nerve Block and Fascia Iliaca Block for Proximal Femoral Fracture in the Elderly Patient: A Meta-analysis

Introduction

Pain management modalities after proximal femoral fracture are variable and have been studied extensively. Regional anesthesia, specifically femoral nerve (FNB) and fascia iliaca compartment blocks (FICB), can be used to provide analgesia preoperatively.

Methods

Systematic searches of all related literature were conducted in the Medline, Embase, and Cochrane Central Register of Controlled Trials databases. Randomized controlled trials (RCTs) of proximal femoral fractures were included. The pain scores at different time points, opioid requirement in 24 h, mean arterial pressure, time for spinal anesthesia, patient satisfaction, and incidence of side effects between the 2 groups were extracted throughout the study.

Results

Fifteen RCTs including 1240 patients met the inclusion criteria. The present meta-analysis indicated that compared with FNB, FICB could decrease the visual analog scale (VAS) scores at 4 h after surgery (P < .05). The incidence of side effects (nausea, vomiting, and sedation) was lower in the FNB group (P < .05). Compared to the FICB, no significant difference was found at any other observed time point. Additionally, no difference was found in opioid requirement at 24 h, mean arterial pressure, time for spinal anesthesia, or patient satisfaction (P > .05).

Conclusions

FICB demonstrates a reduction in VAS score at 4 while FNB decreases the risk of several adverse events. More high-quality RCTs are necessary for proper comparison of the efficacy and safety of FNB and FICB.

Effect of Low-Dose Dexmedetomidine Combined with Lumbosacral Plexus Block Guided by Ultrasound Imaging Based on Image Segmentation Algorithm in Fracture Surgery

The aim of this study was to analyze the application of ultrasound-guided low-dose dexmedetomidine combined with lumbosacral plexus block based on artificial intelligence algorithm in the surgical treatment of proximal femoral fractures. 104 patients with proximal femoral fractures were divided into 52 cases in the experimental group (ultrasound-guided lumbosacral plexus block combined with dexmedetomidine based on local fitting image segmentation algorithm) and 52 cases in the routine group (endotracheal intubation and inhalation combined with general anesthesia). An image segmentation algorithm based on local fitting was constructed to enhance the ultrasound image. It was found that in the routine group, the heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) at the beginning of intravenous injection of dexmedetomidine, during skin incision, and half an hour after skin incision were significantly lower than those at admission (P < 0.05). The pressing times of patient-controlled intravenous analgesia (PCIA) in the conventional group (17.05 ± 6.85 times) were significantly higher than that in the experimental group (8.55 ± 4.12 times), and the difference was statistically significant (P < 0.05). The visual analogue scale (VAS) scores at 1, 5, 10, and 15 after operation in the routine group were significantly higher than those in the experimental group (P < 0.05). The number of dizziness, nausea, and vomiting, venous thrombosis of lower limbs, cardiovascular events, and pulmonary infection in the routine group on the 1st, 2nd, and 3rd days after operation were significantly higher than those in the experimental group (P < 0.05). In summary, the ultrasound-guided lumbar plexus-sacral plexus block combined with dexmedetomidine anesthesia based on image segmentation algorithm can effectively maintain the hemodynamic stability of patients, with remarkable analgesic effect and high safety.

A Preliminary Analysis of a Modified Anterior Approach to Hip Pericapsular Neurolysis for Inoperable Hip Fracture Using the IDEAL Framework

Introduction: With an increasingly ageing population, there is a growing impact of fragility hip fracture on the healthcare system and on society as a whole. Oral and injectable analgesics are often insufficient whilst traction and regional blocks do not allow patients to be discharged easily. While the conventional approach of ultrasound-guided anterior hip pericapsular neurolysis can help a lot of inoperable hip fracture patients to relieve their fracture pain and facilitate subsequent nursing care, enormous technical challenges are encountered in some cases. In this retrospective case study, we evaluated the overall pain and functional outcomes of our modified approach of anterior hip pericapsular neurolysis for inoperable hip fractures using the IDEAL framework. Method: This retrospective case series studied patients with acute inoperable hip fracture who received the modified approach of anterior hip pericapsular neurolysis from January 2018 to June 2019 according to the IDEAL recommendations. The modified approach consisted of pericapsular nerve group (PENG) injection, iliopsoas plane infiltration, and the sagittal approach of obturator nerve articular branches (ONAB) injection. Subsequent alcohol neurolysis would be performed in the same setting if there were positive diagnostic blocks. Assessments were carried out on post-intervention day 5. The primary outcome was pain intensity during hip flexion at 80 degrees in the recumbent position and during gentle hip internal and external rotation using an appropriate pain scoring tool. The secondary outcomes were the range of tolerable hip flexion and occurrence of any lower limb neurological deficit because of the procedure. Interim outcomes were also briefly evaluated. Results: Among the 74 patients who were reviewed in the study period, the median dynamic pain at hip flexion 80° (p < 0.001) and on gentle hip external and internal rotation (p < 0.001) was significantly reduced from a composite score of 3 (severe pain) to 1 (mild pain) on post-intervention day 5 after the modified approach of hip neurolysis. This translated to 72% of patients achieving satisfactory pain control, which was defined as a composite pain score of ≤1 on hip flexion at 80°. Functionally, the mean range of tolerable hip flexion significantly improved from 39.7° at baseline to 74° on post-intervention day 5 (p < 0.001). Transient and reversible hypotension was seen in about 10% of the patients. No other major procedural adverse event was noted. Interim follow-up at 4−6 months post-intervention revealed that more than 95% of patients continued to have satisfactory dynamic pain control (i.e., composite pain score ≤ 1). According to the IDEAL classification, this study could be ranked as stage 2a (development). Conclusions: Our findings suggested that anterior hip pericapsular neurolysis using a modified approach could offer consistent and satisfactory analgesic and functional benefits to a majority of patients with inoperable hip fractures during the interim of the fracture healing process, and it was potentially safer than the conventional approach. This technique might have achieved its readiness to proceed to the next stage of research according to the IDEAL framework.

Is Femoral Nerve Block Superior to Fascia Iliac Block in Hip Surgery? Meta-Analysis of Randomized Controlled Trials

Background. Femoral nerve block (FNB) and fascia iliac compartment block (FICB) are alternative methods of pain relief during hip surgery. Nevertheless, the effectiveness and safety of FNB compared with FICB are yet to be fully determined. Methods. Electronic databases were systematically searched. Only randomized controlled trials (RCTs) on hip surgery were included. Postoperatively, the pain scores at different time points, narcotic requirements in 24 h, mean arterial pressure, spinal anesthesia (SA) time, patient satisfaction, and adverse effect rates between the two groups were extracted throughout the study. Results. Fourteen RCTs including 1179 patients were included. Compared to the FICB, FNB decreased the VAS scores postoperatively at 24 h at rest ( $P<0.05$ ) and the incidence rate of some side effects (nausea, vomiting, and sedation) ( $P<0.05$ ). However, compared to the FICB, no significant difference was found in the FNB regarding the VAS scores postoperatively at any of the other time points (2 min, 20 min, 2 h, 24 h at movement, 48 h at rest, and 48 h at movement). Patients in both groups had similar narcotic needs after 24 h, mean arterial pressure, SA time, and patient satisfaction ( $P>0.05$ ). Conclusions. FNB has more advantages in reducing VAS scores postoperatively at 24 h at rest and the odds of some adverse effects. A better quality RCT is needed to properly compare FNB with FICB.

Femoral nerve block versus fascia iliaca block for pain control in knee and hip arthroplasties: A meta-analysis

BACKGROUND

This meta-analysis aimed to compare the efficiency of fascia iliaca compartment block (FICB) and femoral nerve block (FNB) for pain management in knee and hip surgeries.

METHODS

We searched four electronic databases (Pubmed, Embase, Cochrane library database, Web of Science) from inception to January 2019. Only randomized controlled trials (RCTs) were included. Two review authors independently extracted data for each included study. Primary outcomes were visual analogue scale at 12 hours, 24 hours, 48 hours, total morphine consumption, the length of hospital stay and the occurrence of nausea and vomiting. Standardized mean difference (SMD) or risk ratio (RR) and 95% confidence intervals (CIs) were calculated for continuous outcomes and discontinuous outcomes respectively. We used the Cochrane Risk of Bias tool to assess risk of bias. Stata 12.0 was used for meta-analysis.

RESULTS

Finally, 7 RCTs involving 508 patients (FICB = 254, FNB = 254) were included in this meta-analysis. Compared with FNB group, FICB has no benefit for visual analogue scale at 12 hours (SMD = 0.02, 95% CI, -0.15 to 0.19; P = .820), 24 hours (SMD = -0.02, 95% CI, -0.22 to 0.18; P = .806), and 48 hours (SMD = -0.02, 95% CI, -0.22 to 0.19; P = .872). No significant differences were found regarding total morphine consumption (SMD = -0.07, 95% CI, -0.29 to 0.15; P = .533). What's more, there was no significant difference between the length of hospital stay and the occurrence of nausea and vomiting (P > .05).

CONCLUSION

FICB has equivalent pain control and morphine-sparing efficacy when compared with FNB. More high-quality RCTs are needed to identify the optimal drugs and volume of local infiltration protocols.

Comparison of pericapsular nerve group block versus fascia iliaca compartment block as postoperative pain management in hip fracture surgeries

Background and Objectives:

Methods:

Results:

Conclusion:

Fascia Iliaca Compartment Block for Perioperative Pain Management of Geriatric Patients with Hip Fractures: A Systematic Review of Randomized Controlled Trials

Background

With continuous increase of the aging population, the number of geriatric patients with fragility hip fractures is rising sharply, and timely surgery remains the mainstay of treatment. However, adequate and effective pain control is the precondition of satisfactory efficacy. This systematic review aimed to summarize the use of fascia iliaca compartment block (FICB) as an analgesic strategy for perioperative pain management in geriatric patients with hip fractures.

Methods

PubMed and Embase databases were searched for English published randomized controlled trials (RCTs) reporting application of FICB for pain control of the older adults with hip fractures between January 1^st, 2000, and May 31^st, 2020. The modified Jadad scale was used to evaluate quality of the RCTs included. Primary outcomes of the eligible RCTs were presented and discussed.

Results

A total of 27 RCTs with 2478 cases were included finally. The present outcomes suggested, after admission or in the emergency department (ED), FICB can provide patients with equal or even better pain relief compared with the conventional analgesia methods, which can also reduce additional analgesic consumptions. While, before positioning for spinal anesthesia (SA), FICB is able to offer superior pain control, facilitating SA performance, after surgery FICB can effectively alleviate pain with decreased use of additional analgesics, promoting earlier mobilization and preventing complications.

Conclusions

FICB is a safe, reliable, and easy-to-conduct technique, which is able to provide adequate pain relief during perioperative management of geriatric patients with hip fractures.

Intrathecal Morphine Is Associated with Less Delirium Following Hip Fracture Surgery: A Register Study

Background

Delirium is a common complication after proximal femoral fracture surgery, with pain and opioid consumption as the contributing factors. The administration of intrathecal morphine may decrease these factors postoperatively and potentially reduce delirium.

Objectives

This research aimed to study the association between the use of intrathecal morphine and the occurrence of delirium.

Methods

A retrospective analysis of a prospective register kept in a non-academic hospital in the Netherlands was performed. The register contained data of all patients with proximal femur fractures that were surgically treated with osteosynthesis or prosthesis. Patients receiving spinal anesthesia (SA group) were compared with patients receiving spinal anesthesia with the addition of intrathecal morphine (SIM group). The administration of either SA or SIM was based on the preference of the anesthesiologist. The primary outcome was the incidence of delirium, as defined by the DSM-V classification. The follow-up lasted until hospital discharge. Both univariate and multivariate analyses were performed.

Results

The SA group consisted of 451 patients, and the SIM group included 34 patients. Delirium occurred in 19.7% in the SA group versus 5.9% in the SIM group (P = 0.046). This association remained significant after correction in multivariate analysis (OR of delirium in the SA group, 95% CI: 1.062 - 21.006, P = 0.041). Additionally, multivariate analysis revealed that age, gender, preoperative cognitive impairment, and fracture treatment (osteosynthesis or prosthesis) were independently associated with delirium.

Conclusions

This retrospective study found an independent association between the use of intrathecal morphine and a lower incidence of delirium. This clinically relevant decrease in delirium should be studied in a prospective randomized study.

Femoral nerve blocks for the treatment of acute pre-hospital pain: A systematic review with meta-analysis

BACKGROUND

Pain management is one of the most important interventions in the emergency medical services. The femoral nerve block (FNB) is, among other things, indicated for pre- and post-operative pain management for patients with femoral fractures but its role in the pre-hospital setting has not been determined. The aim of this review was to assess the effect and safety of the FNB in comparison to other forms of analgesia (or no treatment) for managing acute lower extremity pain in adult patients in the pre-hospital setting.

METHODS

A systematic review (PROSPERO registration (CRD42018114399)) was conducted. The Cochrane and GRADE methods were used to assess outcomes. Two authors independently reviewed each study for eligibility, extracted the data and performed risk of bias assessments.

RESULTS

Four studies with a total of 252 patients were included. Two RCTs (114 patients) showed that FNB may reduce pain more effectively than metamizole (mean difference 32 mm on a 100 mm VAS (95% CI 24 to 40)). One RCT (48 patients) compared the FNB with lidocaine and magnesium sulphate to FNB with lidocaine alone and was only included here for information regarding adverse effects. One case series included 90 patients. Few adverse events were reported in the included studies. The certainty of evidence was very low. We found no studies comparing FNB to inhaled analgesics, opioids or ketamine.

CONCLUSIONS

Evidence regarding the effectiveness and adverse effects of pre-hospital FNB is limited. Studies comparing pre-hospital FNB to inhaled analgesics, opioids or ketamine are lacking.

A Randomized Controlled Trial of FNB versus FICB for Patients with Femoral Neck Fractures Before Spinal Anesthesia

Background and Objectives

Patients with femoral neck fractures often suffer severe pain. This randomized controlled clinical study compared the effect of femoral nerve block (FNB) and fascia iliaca compartment block (FICB) in this population.

Patients and Methods

Forty-six patients were randomly assigned to one of the two groups: FNB group (femoral nerve block, n=23) or FICB group (fascia iliaca compartment block, n=23). Before positioning for spinal anesthesia, patients received FNB with 15 mL of 0.5% ropivacaine or FICB with 40 mL of 0.5% ropivacaine. Pain was evaluated using a visual analogue scale (VAS) at rest and during hip flexion after admission to the operation room; at 3, 5, 8, and 10 min after analgesia intervention; and during positioning for spinal anesthesia. Positioning was attempted after 10 min of analgesia intervention in each group. Time required to perform spinal anesthesia, quality of positioning, and patient satisfaction were documented.

Results

The VAS scores in the FNB group were significantly lower than those in FICB group at 3 and 5 min after analgesia intervention (P=0.000). However, there were no significant differences in VAS between groups at 8 or 10 min or during positioning.

Conclusion

FNB and FICB produce similar analgesic effects in patients with femoral neck fractures, but FNB has a more rapid onset of pain relief.

Hip fracture pain management in a regional Australian emergency department: A retrospective descriptive study

BACKGROUND

Hip fractures are a common and painful emergency presentation amongst elderly patients and are associated with significant morbidity and mortality. This study observed the frequency of documentation of pain scores and use of nerve blocks in hip fracture patients in a regional Australian ED and describes current practice in relation to national guidelines.

METHODS

This was a retrospective single-site observational study and included all patients with a recorded ED diagnosis of fracture neck of femur over the age of 18 presenting between 1 July 2017 and 31 December 2017 to a regional ED. Data collection included patient demographics, pain scores and analgesia administered.

RESULTS

Ninety-three patients were included in analysis. This population had a high proportion of patients who had a residential address remote to the base hospital. Thirty-eight patients (41%) had a documented pain score within 30min and the frequency of nerve blocks was 45%.

CONCLUSION

Management of pain for patients with hip fracture in this regional ED varied from Australian guidelines and practice in other Australian EDs, demonstrating potential areas for further research and quality improvement in assessing and treating pain in older adults. Geographic remoteness may be an important factor.

Comparison of preoperative ultrasound guided fascia iliaca block versus femoral nerve block for proximal femur fractures before positioning for spinal anesthesia: an observational study

Background

Severe pain associated with proximal femur fractures makes the positioning for regional anesthesia a challenge. Systemic administration of analgesics can have adverse effects. Individually, both the fascia iliaca block (FIB) and femoral nerve blocks (FNB) have been studied. However, there is little evidence comparing the two. The aim of this study was to compare the overall efficacy of the two blocks in patients with proximal femur fracture before positioning for spinal anesthesia.

Methods

ASA (American Society of Anesthesiologists) class I, II, and III patients scheduled for elective and emergency surgery with the diagnosis of proximal femur fracture between October 2018 and June 2019 were included in the study. The patients were assigned to two groups by convenience nonprobability sampling of 35 each.

Results

Our study showed a reduction in visual analogue scale scores at 3, 4, and 5 minutes after administration of the FIB being 5.1 ± 1.1, 4.1 ± 1.3, and 2.8 ± 0.8, and those after the FNB as 4.4 ± 1.1, 3.3 ± 1.1, and 2.1 ± 1.4 with P < 0.05, which was statistically significant. The mean first rescue analgesia time for the FIB was 7.1 ± 2.1 hours, while for the FNB it was 5.2 ± 0.7 hours. The P value was less than 0.001, which was significant.

Conclusions

Both ultrasound guided FNB and FIB techniques provide sufficient analgesia for patient's positioning before spinal anesthesia. However, the duration of postoperative analgesia provided by FIB was greater than that of the FNB.

The Feasibility of the Ultrasound-Guided Femoral Nerve Block Procedure with Low-Dose Local Anesthetic in Intracapsular and Extracapsular Hip Fractures

BACKGROUND

The local anesthetic dosages used in the current literature in regional applications of local anesthetics are frequently high for surgical purposes, and there are no sufficient dosage studies for emergency department (ED) management.

OBJECTIVES

The aim of this study was to determine the success of lower local anesthetic dosages capable of reducing costs and excessive exposure to drugs in pain control in patients with femoral neck fractures (FNFs) in the ED.

METHODS

Patients ≥65 years of age with FNFs and reporting Wong-Baker Pain Rating Scales scores ≥8 were included in this prospective, interventional study. Patients underwent ultrasound-guided regional femoral block with 5 mL 2% prilocaine. Pain scores before the procedure and at 30 min and 2 h postprocedure were compared with the Friedman test and Wilcoxon test with Bonferroni correction.

RESULTS

Forty patients, 20 with intracapsular and 20 with extracapsular FNFs, were enrolled. The initial pain scores of patients with both intra- and extracapsular fractures were 8 (range 8-10). A statistically significant 50% decrease in pain scores was observed in both groups 30 min after the regional block procedure (p < 0.001). A statistically significant 75% decrease in pain scores was observed in both groups 2 h after the regional block procedure (p < 0.001). No statistically significant difference was determined in the change in 30-min and 2-h pain scores between the groups.

CONCLUSIONS

The administration of 5 mL 2% prilocaine for pain control in FNFs in elderly patients in the ED can reduce systemic analgesic requirements by establishing effective analgesia in both intracapsular and extracapsular fractures.