Emergency physician-performed ultrasound-guided nerve blocks in proximal femoral fractures provide safe and effective pain relief: a prospective observational study in The Netherlands

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.

Key Considerations for Frail Patients Undergoing Hip Fracture Surgery

Improving preoperative care for elderly patients with hip fractures is crucial for achieving the best outcomes. A multidisciplinary team that can improve overall care quality by addressing patient's medical conditions, analgesia, timely surgery, and early postoperative mobilization is required. This narrative review provides insights regarding the extent of preoperative optimization needed for hip fracture surgery.

Femoral nerve blocks versus standard pain control for hip fractures: a retrospective comparative analysis

OBJECTIVE

Pain control for hip fractures is often achieved via intravenous opioids. However, opioids can have dangerous adverse effects, including respiratory depression and delirium. Peripheral nerve blockade is an alternative option for pain control that reduces the need for opioid analgesia. The purpose of this study was to compare the use of femoral nerve blocks versus standard pain control for patients with hip fractures.

METHODS

This retrospective study included adult patients presenting to the emergency department with isolated hip fractures between April 2021 and September 2022. The intervention group included all patients who received a femoral nerve block during this time. An equivalent number of patients who received standard pain control during that period was randomly selected to represent the control group. The primary outcome was preoperative opioid requirement, assessed by morphine milligram equivalents (MMEs).

RESULTS

During the study period, 90 patients were included in each group. Mean preoperative MME was 10.3 (95% confidence interval [CI], 7.4-13.2 MME) for the intervention group and 14.0 (95% CI, 10.2-17.8 MME) for the control group (P=0.13). Patients who received a femoral nerve block also had shorter time from emergency department triage to hospital discharge (7.2 days; 95% CI, 6.2-8.0 days) than patients who received standard care (8.6 days; 95% CI, 7.210.0 days). However, this difference was not statistically significant (P=0.09).

CONCLUSION

Femoral nerve blockade is a safe and effective alternative to opioids for pain control in patients with hip fractures.

Effect of early ultrasound-guided femoral nerve block on preoperative opioid consumption in emergency patients with hip fracture: a randomized trial

BACKGROUND AND IMPORTANCE

Ultrasound-guided femoral nerve block (FNB) could be used as part of a multimodal preoperative pain management for patients with hip fracture. Evidence of the effects of its early implementation in the emergency room as an immediate alternative to intravenous morphine titration is sparse.

OBJECTIVE

To investigate the effect of an early ultrasound-guided FNB performed by emergency physicians on preoperative opioid consumption, compared to standard pain management.

DESIGN, SETTING, AND PARTICIPANTS

This open randomized controlled trial was conducted in the Emergency Department of a French hospital with patients with neck or trochanteric femoral fracture who had a pain score ≥7 out of 10 points at triage.

INTERVENTION

Patients were randomized to receive an initial analgesia with an early ultrasound-guided FNB or with standard pain management. The continuation of pain treatment followed standardized pain control guidelines until hospital discharge in both groups.

OUTCOME MEASURE AND ANALYSIS

The primary outcome was preoperative opioid consumption truncated 48h after triage time, and converted in morphine milligram intravenous equivalents (MME). Secondary outcomes were time to pain relief, time for regaining walk, opioid consumption and occurrence of opioid and FNB adverse effects during the hospital stay. Exploratory outcomes included ease and duration of the procedure.

MAIN RESULTS

We randomized 35 patients: 17 to standard pain management and 18 to ultrasound-guided FNB, among whom 30 patients completed the protocol. The median of preoperative opioid consumption was reduced by 60% in the ultrasound-guided FNB group compared to standard group [6 MME (3-9) vs. 15 MME (11-18)], with a consumption difference of 9 MME (95% CI: 3-14, P  < 0.001). Throughout hospital stay, opioid consumption was reduced by 56% in the ultrasound-guided FNB group compared to standard group, with a consumption difference of 11.5 MME (95% CI: 0.5-22).Times to pain relief and for regaining walk did not differ between groups. Opioid adverse events occurrence were reduced by 40% (95% CI: 5.1-74.9) in the ultrasound-guided FNB group compared to standard group. No adverse effects of FNB have been detected.

CONCLUSION

Early ultrasound-guided FNB resulted in reducing preoperative opioid consumption, without delaying time to pain relief.

Nurse-led ultrasound-guided femoral nerve block: A randomised controlled trial of two different patient flow systems in an emergency department

INTRODUCTION

Elderly with hip fractures present complex challenges. Effective pain management is crucial for recovery and quality of life. However, pain control can be difficult and requires customized care.

METHODS

We conducted an unblinded, randomised controlled trial investigating the effects of ultrasound-guided femoral nerve block in patients with hip fracture performed by specially trained nurses (Group Nurse) compared to anaesthesiologists (Group Anaesthesiologist). The hypothesis was that a single shot ultrasound-guided femoral nerve block would result in a total summarized lower dynamic numeric rating scale score for pain intensity during the first 120 min after admission for patients in Group Nurse compared to Group Anaesthesiologist measured in five timepoints. The primary outcome was measured by a cumulative numeric rating scale score for dynamic pain (with flexion of the hip until maximum 30° from bed surface) during the first 120 min after admission to the emergency department.

RESULTS

From February 2020 to June 2021, 263 patients were screened, of which 42 (16.0%) consented and were randomly allocated; 21 in each arm. The primary outcome was not different between groups (p = 0.24), and displayed no substantial superiority of specially trained nurses over anaesthesiologist. No complications or adverse effects were observed in either group. The use of systemic analgesics and the development of delirium was similar between the two groups. In the Nurse Group, patients were administered their ultrasound-guided femoral nerve block earlier.

CONCLUSION

Our study did not demonstrate a statistically significant beneficial effect of specially trained nurses over anaesthesiologist on cumulative pain in performing ultrasound-guided femoral nerve blocks, while no side-effects/complications or adverse effects were observed in either group.

CLINICALTRIAL

The trial was registered on October 31, 2019 at Clinicaltrials.gov (NCT04145752).

Artificial intelligence technology and ultrasound-guided nerve block for analgesia in total knee arthroplasty

BACKGROUND

Knee diseases are more common in middle-aged and elderly people, so artificial knee replacement is also more used in middle-aged and elderly people. Although the patient's pain can be reduced through surgery, often accompanied by moderate pain after surgery and neutralization, which not only increases the psychological burden of the patient, but also greatly reduces the postoperative recovery effect, and may also lead to the occurrence of postoperative adverse events in severe cases.

AIM

To investigate the analgesic effect of artificial intelligence (AI) and ultrasound-guided nerve block in total knee arthroplasty (TKA).

METHODS

A total of 92 patients with TKA admitted to our hospital from January 2021 to January 2022 were opted and divided into two groups according to the treatment regimen. The control group received combined spinal-epidural anesthesia. The research group received AI technique combined with ultrasound-guided nerve block anesthesia. The sensory block time, motor block time, visual analogue scale (VAS) at different time points and complications were contrasted between the two groups.

RESULTS

The time of sensory block onset and sensory block perfection in the research group was shorter than those in the control group, but the results had no significant difference (P > 0.05). Duration of sensory block in the research group was significantly longer than those in the control group (P < 0.05). The time of motor block onset and motor block perfection in the research group was shorter than those in the control group, but the results had no significant difference (P > 0.05). Duration of motor block in the research group was significantly longer than those in the control group. The VAS scales of the research group were significantly lower than that of the control group at different time points (P < 0.05). The postoperative hip flexion and abduction range of motion in the research group were significantly better than those in the control group at different time points (P < 0.05). The incidence of complications was significantly lower in the research group than in the control group (P = 0.049).

CONCLUSION

In TKA, the combination of AI technology and ultrasound-guided nerve block has a significantly effect, with fewer postoperative complications and significantly analgesic effect, which is worthy of application.

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.

Ultrasound-Guided Peripheral Nerve Blocks: A Practical Review for Acute Cancer-Related Pain

PURPOSE OF REVIEW

Ultrasound-guided regional techniques, including catheter-based approaches, are a subset of interventional therapies that have gained interest as an option for managing acute cancer-related pain. The authors sought to review the available published evidence and to discuss practical recommendations for expanding access to such therapies.

RECENT FINDINGS

In a MEDLINE/Pubmed search of ultrasound-guided peripheral nerve blocks and peripheral nerve catheters for specific anatomic targets, a total of 28 case reports and case series were identified. Included studies described improved analgesia and reduced opioid requirements with highly variable duration of effect. Current level of evidence remains limited. Pain is a symptom that markedly impacts the quality of life of cancer patients and ultrasound-guided regional techniques are a promising therapeutic option albeit with a limited evidence base. Practical recommendations offered for coordinating access to such therapies in the inpatient, emergency department, and outpatient settings may expand interest and facilitate higher quality research.

Comparison between femoral block and PENG block in femoral neck fractures: A cohort study

BACKGROUND

Regional analgesia is worth performing in the multimodal postoperative management of hip fracture (HF) because it reduces hospital morbidity and mortality. The aim of this study is to compare the efficacy and side effects of the recently described "Pericapsular Nerve Group (PENG) Block" with those of the femoral block, which is considered the standard of care for postoperative pain control after femoral neck fracture.

MATERIALS AND METHODS

We conducted a comparative observational study at a university hospital (Saint Antoine Hospital, Sorbonne University, Paris, France), where the PENG block was introduced in August 2019. We include all patients from June to October 2019, who were coming for femoral neck fractures and who had an analgesic femoral block or PENG block before their surgery. The primary outcome was the comparison of cumulative postoperative morphine consumption 48 hours after surgery.

RESULTS

Demographics, medical charts, and perioperative data of 42 patients were reviewed: 21 patients before (Femoral group) and 21 patients after the introduction of PENG block (PENG group) in clinical practice. Thirteen total hip arthroplasties (THA) and eight hemi arthroplasties (HA) were included in each group. Demographics were also comparable. The median, postoperative, morphine equivalent consumption at 48 hours was 10 [0-20] mg and 20 [0-50] mg in Femoral and PENG groups respectively (p = 0.458). No statistically significant differences were found in postoperative pain intensity, time to ambulation, incidence of morphine-related side effects, or length of hospital stay. The postoperative muscle strength of the quadriceps was greater in the PENG group than in the Femoral group (5/5 vs. 2/5, p = 0.001).

CONCLUSION

In the management of hip fractures, PENG block is not associated in our study with a significant change in postoperative morphine consumption, compared to femoral block. However, it does significantly improve the immediate mobility of the operated limb, making it appropriate for inclusion in enhanced recovery programs after surgery.

Regional anaesthesia for rib fractures: A pilot study of serratus anterior plane block

OBJECTIVE

Rib fractures are not only painful but are associated with morbidity and mortality, especially in older patients. The serratus anterior plane block (SAPB) is a plane block distant from major neurovascular bundles and may provide anaesthesia to a substantial area of the hemithorax. This pilot study was designed to assess if the SAPB can be safely and efficiently incorporated to the trauma reception workflow of an adult, level 1 trauma centre.

METHODS

A convenience sample of 20 adult patients with at least two or more unilateral rib fractures received a SAPB performed by an emergency physician in addition to their standard analgesic regime. Time to perform the procedure, the number of attempts and complications were recorded as feasibility measures. Secondary outcome was the safety of the block. Numerical pain scores at pre-determined time points over 4 h, the diagnosis of hospital-acquired pneumonia, hospital length of stay and mortality at hospital discharge were collected to provide pilot data on effectiveness.

RESULTS

The median time to perform the procedure was 5.5 (interquartile range 4.6-10) mins with a range of 2-10.5 min. Most (16; 80%) SAPBs were completed in a single attempt. There were no documented complications. Median pain scores reduced from 6.5 (6-8) and were maintained at 3 (2-5) at 4 h after the SAPB.

CONCLUSIONS

The present study demonstrated the feasibility of ultrasound-guided SAPB among patients with multiple rib fractures in the ED. No complications were observed. Further prospective evaluation of analgesic effects in a larger cohort is indicated.

Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel

Background

Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments.

Objective

To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments.

Eligibility criteria

All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms.

Sources of evidence

PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles.

Charting methods

Evidence was searched according to clinically relevant topics and PICO questions.

Results

Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland.

Conclusions

Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.

Learning process of ultrasound-guided Ilio-fascial compartment block on a simulator: a feasibility study

BACKGROUND

Ultrasound-guided fascia iliaca compartment block (US-FICB) is not part of the learning curriculum of the emergency physicians (EP) and is usually performed by anesthesiologists. However, several studies promote EP to use this procedure. The goal of this study was to assess the feasibility of a training concept for non-anesthesiologists for the US-FICB on a simulator based on a validating learning path.

METHOD

This was a feasibility study. Emergency physicians and medical students received a 1-day training with a learning phase (theoretical and practical skills), followed by an assessment phase. The primary outcome at the assessment phase was the number of attempts before successfully completing the procedure. The secondary outcomes were the success rate at first attempt, the length of procedure (LOP), and the stability of the probe, corresponding to the visualization of the needle tip (and its tracking) throughout the procedure, evaluated on a Likert scale.

RESULTS

A total of 25 participants were included. The median number of attempts was 2.0 for emergency physicians and 2.5 for medical students, and this difference was not significant (p = 0.140). Seven participants (28%) succeeded at the first attempt of the procedure; the difference between emergency physicians and medical students was not significant (37% versus 21%; p = 0.409). The average LOP was 19.7 min with a significant difference between emergency physicians and medical students (p = 0.001). There was no significant difference regarding the stability of the probe between the two groups.

CONCLUSION

Our 1-day training for non-anesthesiologists with or without previous skills in ultrasound seems to be feasible for learning the US-FICB procedure on a simulator.

Pre-operative femoral nerve block for hip fracture-A systematic review with meta-analysis

BACKGROUND

Pre-operative pain management of hip fracture patients is complex. Femoral nerve block (FNB) is used for hip fractures to reduce pain and demand for systematic analgesia. The objective of the study was to systematically investigate the efficacy of single-shot FNB for hip fracture patients.

METHODS

Five databases were searched from inception until 8 May 2019. We included randomized controlled trials (RCT's) assessing pain relief in patients with hip fractures. Intervention was pre-operative FNB compared to any systemic analgesic (eg opioids, non-steroidal anti-inflammatory drugs or paracetamol). Primary outcomes assessed were pre-operative pain and use of rescue analgesics. Secondary outcome was cognitive impairment. We present a bias assessment, a meta-analysis and a grading of certainty of evidence.

RESULTS

We included five trials (n = 254), where participants received FNB 30 minutes or more prior to surgery; all were judged as having high risk of bias. All studies found significantly decreased pain scores at least once in the intervention group compared to the control group. Meta-analysis on the primary outcome of pain showed significance. Mean difference was -2.13 point (in cm) (CI:-3.53,-0.72) on visual analogue scale in the intervention group, but is judged low on certainty.

CONCLUSIONS

The quantity of evidence supporting pre-operative single-shot FNB for hip fractures is very low, and the certainty of evidence supporting pre-operative single-shot FNB for hip fractures is low. No studies using ultrasound guided technique were identified. Data on non-ultrasound guided FNB's suggest a decreased pain score compared to the use of systemic analgesia.