Improvement of analgesic efficacy for total hip arthroplasty by a modified ultrasound-guided supra-inguinal fascia iliaca compartment block

The Effectiveness of Quadratus Lumborum and Fascia Iliaca Blocks on Patient Outcomes in Hip Arthroplasty

Hip arthroplasty is a common procedure with high costs and difficult rehabilitation. It causes postoperative pain, and this can reduce mobility which extends in-patient time. An optimal analgesia regime is crucial to identify. Opioids produce effective pain relief but are associated with nausea, vomiting, and respiratory depression which can hinder physiotherapy and discharge. Finding alternatives has been of interest in recent years, particularly fascial blocks. These are anaesthetic injections beneath fascia which spread to nerves providing pain relief from surgery and are used with a general or spinal anaesthetic. Two of these blocks which are of interest to total hip arthroplasty are the quadratus lumborum block and fascia iliaca block. Studies have investigated the effectiveness of these blocks through patient factors, primarily pain scores, opioid consumption, and other secondary outcomes such as ambulation and length of stay. This review takes a narrative approach and investigates the literature around the topic. Pain and opioid consumption were the most widely reported outcomes, reported in 90% and 86% of studies. 83% of these studies reported positive effects on pain scores when FIB was utilised. 80% of these studies reported positive effects on opioid consumption when FIB was used. When QLB block was utilised, pain and opioid consumption were positively impacted in 82% of studies. This paper has been written with the intention of reviewing current literature to give an impression of the effectiveness of the blocks and propose potential areas for future work on the blocks.

Pericapsular nerve group block versus fascia iliaca block for perioperative analgesia in hip fracture surgery: a prospective randomized trial

The aim of our study was to evaluate the efficacy of the pericapsular nerve group block (PENG) versus the supra-inguinal fascia iliaca compartment block (SI-FICB) to improve analgesia during positioning for spinal anesthesia (SA) for hip fracture surgery. We conducted a prospective randomized clinical trial involving patients who will undergo hip fracture surgery under SA and randomized into two groups: the PENG group: patients who received PENG block with 10 ml of 0.25% bupivacaine and 10 ml of 2% lidocaine and the SI-FICB group: patients who received SI-FICB block with the same solution. Our primary outcome was the Visual Analogue Scale (VAS) score at positioning for SA. Secondary outcomes were VAS after the block, the ease of spinal positioning (EOSP), the time to perform the block, the postoperative morphine consumption, and the VAS score at the 3rd, 6th, 12th, and 24th postoperative hours. Eighty-nine patients were enrolled and randomized into two groups: 44 in the PENG group and 45 in the SI-FICB group. The time of block performance was comparable in both groups (p = 0.195). There was a significant decrease in pain scores in the 2 groups, 20 min after the blocks at rest and while positioning for SA. PENG block provided better analgesia than SI-FICB block at positioning (P=0.046) with no significant difference in the ease of positioning (p=0.328). The morphine consumption was comparable in the 2 groups (p = 0.842). There was no significant difference in VAS scores at the 3rd, 6th, 12th, and 24th postoperative hours with p respectively 0.061, 0.767, 0.198, and 0.130. Both PENG and SI-FICB blocks provided adequate perioperative analgesia with the superiority of the PENG block in the sitting position for SA.

Circum-Psoas Block versus Supra-Inguinal Fascia Iliaca Block for Postoperative Analgesia in Patients Undergoing Total Hip Arthroplasty: A Randomized Clinical Trial

Purpose

Total hip arthroplasty (THA) is often associated with moderate to severe pain. The present study compared the efficacy of circum-psoas block (CPB) with supra-inguinal fascia iliaca block (SIFIB) for postoperative analgesia in patients undergoing THA.

Patients and Methods

In this randomized trial, sixty-four patients undergoing THA were allocated randomly to the CPB group or SIFIB group with 40 mL of 0.3% ropivacaine. The primary outcome was dynamic pain score at 6 h postoperatively. Secondary outcomes included dynamic pain scores at 12, 24 and 48 h; static pain scores; sensory and motor block; opioid consumption; time to first opioid request; length of hospital stay; patient satisfaction; and adverse events.

Results

CPB patients showed significantly lower dynamic pain scores at 6 (3.11 ± 0.66 vs 4.47 ± 0.74, respectively; P = 0.000), 12 (2.52 ± 0.73 vs 3.53 ± 0.85, respectively; P = 0.000) and 24 h (2.30 ± 0.57 vs 2.87 ± 0.71, respectively; P = 0.001) after surgery, as well as lower static pain scores at 6 and 12h (P = 0.001 and P = 0.033 respectively) than SIFIB patients. Lower opioid consumption was observed in the CPB group at 24 and 48 h (P = 0.000, both) than in the SIFIB group. Patients in the CPB group reported improved quadriceps strength at 6 and 12 h (P = 0.000, both), as well as better muscle strength of hip flexion at 6, 12 and 24 h (P = 0.000, P = 0.000 and P = 0.025 respectively). Compared with SIFIB, CPB was associated with increased sensory block coverage at 6, 12 and 24 h (P = 0.000, P = 0.000, and P =0.022, respectively).

Conclusion

CPB has a greater potential to alleviate postoperative pain and improve recovery in THA patients than SIFIB.

Evaluation of Postoperative Analgesic Efficacy of Ultrasound-Guided Suprainguinal Fascia Iliaca Block in Knee Arthroplasty: Prospective, Randomized, Feasibility Study

BACKGROUND

Total Knee Arthroplasty (TKA) is one of the most commonly performed orthopedic procedures, and patients complain of severe pain in the postoperative period. The supra-inguinal fascia iliaca block (SIFIB) works as an anteriorly applied lumbar plexus block and is frequently used in hip surgeries. In this study, we evaluated the effect of SIFIB in patients undergoing TKA under spinal anesthesia.

METHODS

This study is a prospective, randomized, assessor-blinded feasibility study conducted in a tertiary hospital. Eighty-six patients with ASA I-III were initially enrolled, and after exclusions, 80 patients were randomized into two equal groups (SIFIB and control groups). The standard multimodal analgesia was applied to the control group, while SIFIB was additionally applied to the block group. The study measured the morphine requirement in PCA and pain intensity using Numeric Rating Scores between the two groups.

RESULTS

the 24-h cumulative morphine consumption was lower in Group SIFIB. Although there was a decrease in NRS at rest scores in the SIFIB group during some time periods, pain was moderate, and no differences in pain scores were recorded during exercise in all patients.

CONCLUSIONS

In patients undergoing TKA under spinal anesthesia, a single shot of SIFIB results in a significant reduction in the amount of morphine consumed in hours. This effect was most likely related to a decrease in pain at rest in the SIFIF group.

Comparison between pericapsular nerve group (PENG) block with lateral femoral cutaneous nerve block and supra-inguinal fascia iliaca compartment block (S-FICB) for total hip arthroplasty: a randomized controlled trial

PURPOSE

To assess the efficacy of pericapsular nerve group (PENG) block combined with lateral femoral cutaneous nerve (LFCN) block in controlling postoperative pain and promoting recovery of lower extremity after total hip arthroplasty (THA), and to compare its effectiveness with supra-inguinal fascia iliaca compartment block (S-FICB).

MATERIALS AND METHODS

92 patients undergoing THA with general anesthesia were randomly allocated to receive either a PENG with LFCN block (n = 46) using 30 ml 0.33% ropivacaine (20 ml for PENG block, 10 ml for LFCN block), or an S-FICB (n = 46) using 30 ml 0.33% ropivacaine. The primary outcome was the time to first postoperative walk. The secondary outcomes included intraoperative remifentanil consumption, postoperative hip flexion degree and muscle strength of the operative lower limbs in the supine position, pain scores (static and dynamic), rescue analgesia, postoperative nausea and vomiting (PONV), and nerve block-related complications.

RESULTS

The combination of PENG with LFCN blocks resulted in an earlier first postoperative walking time (19.6 ± 9.6 h vs 26.5 ± 8.2 h, P < 0.01), greater postoperative hip flexion degree at 6 h, 24 h and 48 h (all P < 0.01), and higher muscle strength of the operative lower limbs at 6 h after surgery (P = 0.03) compared to S-FICB. The difference in pain scores (static and dynamic) was only statistically significant at 48 h (P < 0.05). There were no differences in the other outcomes.

CONCLUSIONS

PENG with LFCN blocks is more effective than S-FICB in shortening the time to first postoperative walk and preservation hip motion after THA, which makes it a suitable addition to enhanced recovery programs following surgery.

Applicability and effectiveness of ultrasound combined with nerve stimulator-guided lumbosacral plexus block in the supine versus lateral position during surgeries for lower limb fracture-a prospective randomized controlled trial

BACKGROUND

Patients with lower limb fracture often have acute pain and discomfort from changes in position, and such pain affects early postoperative recovery. This study aimed to compare the applicability and effectiveness of ultrasound combined with nerve stimulator-guided lumbosacral plexus block (LSPB) in the supine versus lateral position during lower limb fracture surgery.

METHODS

We included 126 patients who underwent elective internal fixation for lower limb fracture who were divided into the S group and the L group by the random number table method and underwent LSPB guided by ultrasound combined with a nerve stimulator in the supine and lateral positions, respectively. The primary outcome was the dose of sufentanil used in surgery. The secondary outcomes were the maximum VAS (visual analogue scale) pain score at position placing for LSPB, the time of position placing, the time for nerve block,the number of puncture attempts,the haemodynamic indicators, the VAS score at 1, 12, and 24 h following surgery, postoperative satisfactory degree to analgesia and adverse events related to nerve block.

RESULTS

There was no statistically significant difference in dose of sufentanil used between the two groups(P = 0.142). The maximum VAS pain score at position placing(P < 0.01), the time of position placement(P < 0.01), the time for lumbar plexus block and the time of puncture attempts were significantly lower in the S group than in the L group (P < 0.01). However, the time for sacral plexus block was higher in the S group than in the L group (P = 0.029). There was no significant difference in haemodynamic indicators,number of puncture attempts for the sacral plexus, postoperative VAS scores, postoperative satisfactory degree to analgesia or adverse events related to nerve block between the two groups (all P > 0.05).

CONCLUSIONS

Our study provides a more comfortable and better accepted anaesthetic regimen for patients undergoing lower limb fracture surgery. LSPB in the supine position is simple to apply and has definite anaesthetic effects. Additionally, it has a high level of postoperative analgesia and therefore should be widely applied.

TRIAL REGISTRATION

The trial was registered prior to patient enrolment at the Chinese Clinical Trail Registry (Date:11/03/2021 Number: ChiCTR2100044117 ).

Ultrasound-guided supra-inguinal fascia Iliaca compartment block for older adults admitted to the emergency department with hip fracture: a randomized controlled, double-blind clinical trial

Background

Hip fracture is common in older adults, and can cause severe post-fracture pain. Fascia iliaca nerve block has consequently been used for preoperative analgesia.

Methods

We performed a randomized, controlled, double-blind clinical trial and recruited older patients with hip fractures. These patients were randomized into two groups and received ultrasound-guided fascia iliaca compartment block using either the supra-inguinal approach (group F) or the classical approach (group C). Heart rate, blood pressure, and resting and exercising visual analog scales were recorded before the procedure and at 30 min, and 6, 12, and 24 h after completion of the procedure. We recorded the duration of the procedure—as well as complications such as bleeding, hypotension, and intractable vomiting; the sleep duration in a 24 h period was also documented.

Results

A total of 38 patients completed the trial, and we observed no differences in the baseline characteristics or pre-procedural measurements between the two groups. Compared with the patients in group C, patients in group F exhibited significantly lower exercising VAS scores at 6 and 12 h after the procedure, faster heart rates at 6 and 24 h after the procedure, a longer procedural duration, and a longer sleep duration. There were no differences in the frequencies of complications between the two groups. The percentages of patients who took oral analgesics and the numbers of medications consumed were also not different between the two groups.

Conclusions

The supra-inguinal FICB provided effective analgesia and improved exercise tolerance compared with the classical approach.

Trial registration

The trial was registered at the Chinese Clinical Trial Registry (registration number: ChiCTR2100045644, registration date: 2021 April 20).

New peripheral nerve blocks and local anesthetics

PURPOSE OF REVIEW

To describe current developed regional blocks, their indications and clinical use. Furthermore, describe new local anesthetics recently introduced and the new agents in pipeline.

RECENT FINDINGS

There are multiple new blocks recently developed with the introduction of ultrasound to regional anesthesia and studies demonstrate effect in different surgical procedures. However, majority of the studies do not compare with gold standard and are relatively small to change clinical practice. Some of these blocks are: erector spinae plane block, infiltration between the popliteal artery and capsule of the posterior knee, pectoral nerve blocks, quadratus lumborum and transversus abdominis plane block. New local anesthetics and adjuvants have been developed in recent years. However, the studies with even with the oldest one introduced Exparel is currently questioned, large future studies are needed to determine efficacy and safety profile and compared with conventional local anesthetics.

SUMMARY

New regional block techniques and new local anesthetics have been introduced recently. However, the efficacy/safety and comparison to conventional techniques and local anesthetics are still needed. Future studies must focus on prolonging analgesia with least invasive regional technique and compare new local anesthetics with current ones.