Fascia iliaca compartment block versus no block for pain control after lower limb surgery: a meta-analysis

The safety of continuous fascia iliaca block in patients with hip fracture taking pre-injury anticoagulant and/or antiplatelet medications

BACKGROUND

Fascia iliaca compartment block (FICB) is an effective method to treat pain in adult trauma patients with hip fracture. Of importance is the high prevalence of preinjury anticoagulants and antiplatelet medications in this population. To date, we have not identified any literature that has specifically evaluated the safety of FICB with continuous catheter infusion in patients on antiplatelet and/or anticoagulant therapy. The purpose of this study is to quantify the complication rate associated with FICB in patients who are actively taking prescribed anticoagulant and/or antiplatelet medications prior to injury and identify factors that may predispose patients to an adverse event.

METHODS

This retrospective study included consecutive adult trauma patients (age ≥18) with hip fracture who underwent placement of FICB within 24 h of admission and had been taking anticoagulant and/or antiplatelet medications pre-injury. Patients were excluded if their catheter was placed more than 24 h post-hospital admission. Patients were evaluated for demographics, injury severity, laboratory values, medication history, receipt of coagulation-related reversal medications, and complications related to FICB placement. Complications included bleeding at the insertion site requiring catheter removal and 30-day catheter site infection. The incidence of complications was reported and risk factors for complications were identified using univariate and multivariate statistics.

RESULTS

There were 124 patients included. The mean age was 81 ± 10 years, and the most common mechanism was ground level fall (94%). Most patients were taking single antiplatelet therapy (65%), followed by anticoagulant alone (21%), combined antiplatelet and anticoagulant therapy (7.3%) and dual antiplatelet therapy (7.3%). The most common antiplatelet was aspirin (88%) and the most common anticoagulant was warfarin (60%). Of the patients taking warfarin, the average INR on admission was 2.3 ± 0.8. Only 1 bleeding complication (0.8%) was noted in a patient prescribed clopidogrel pre-injury which occurred 5 days post-catheter placement. This same patient was noted to have superficial surgical site bleeding most likely secondary to the use of enoxaparin for post-operative deep venous thrombosis prophylaxis. There were 4 orthopedic superficial surgical site infections (3.2%), all remote from the catheter site. The pre-injury medication prescribed in these patients was aspirin 81 mg, aspirin 325 mg, rivaroxaban and dabigatran, respectively. No factors were associated with a complication thus multivariate analysis was not performed.

CONCLUSION

The incidence of complications associated with fascia iliaca compartment block (FICB) in adult trauma patients prescribed pre-injury anticoagulants or antiplatelet medications is low. In this retrospective review, we did not identify any complications that were directly associated with the FICB procedure. Fascia iliaca block with continuous infusion catheter placement can be safely performed on patients who are on therapeutic anticoagulant and/or antiplatelet agents.

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.

The impact of fascia iliaca compartment block on chronic postsurgical pain in patients undergoing hip fracture repair

STUDY OBJECTIVE

Chronic postsurgical pain (CPSP), i.e. pain persisting >3 months, may appear after any type of surgery. There is a paucity of literature addressing CPSP development after hip fracture repair and the impact of any analgesic intervention on the development of CPSP in patients after hip fracture surgery. This study is the first aiming to examine the impact of ultrasound-guided fascia iliaca compartment block (USG FICB) on the development of CPSP after hip fracture repair.

DESIGN

Prospective randomized study.

SETTING

Operating room.

PATIENTS

182 patients scheduled for hip fracture surgery.

INTERVENTIONS

Patients were randomized to receive a USG FICB (FICB group) or a sham saline injection (sham FICB group), twenty minutes before positioning for spinal anesthesia.

MEASUREMENTS

The hip - related characteristic pain intensity (CPI) at 3- months post-surgery was the primary outcome measure. Presence and severity of hip-related pain at 3- and 6-months post-surgery, numeric rating pain scale (NRS) scores at 6, 24, 36, 48 postoperative hours, total 24-hour tramadol PCA administration and timing of the first tramadol dose, were documented as well.

MAIN RESULTS

FICB group presented with lower CPI scores 3- months postoperatively (p < 0.01), as well as lower percentage of patients with high-grade CPSP, 3 and 6 months postoperatively (p < 0.001). FICB group also showed significantly lower NRS scores in all instances, lower total 24 - hour tramadol consumption and higher mean time to first tramadol dose (p < 0.05). The overall sample of 182 patients reported a considerably high incidence of hip -related CPSP (60% at 3 months, 45% at 6 months).

CONCLUSIONS

USG FICB in the perioperative setting may reduce the incidence, intensity and severity of CPSP at 3 and 6 months after hip fracture surgery, providing safe and effective postoperative analgesia.

Confronting the Opioid Crisis: Practical Pain Management and Strategies: AOA 2018 Critical Issues Symposium

The United States is in the midst of an opioid crisis. Clinicians have been part of the problem because of overprescribing of narcotics for perioperative pain management. Clinicians need to understand the pathophysiology and science of addiction to improve perioperative management of pain for their patients. Multiple modalities for pain management exist that decrease the use of narcotics. Physical strategies, cognitive strategies, and multimodal medication can all provide improved pain relief and decrease the use of narcotics. National medical societies are developing clinical practice guidelines for pain management that incorporate multimodal strategies and multimodal medication. Changes to policy that improve provider education, access to naloxone, and treatment for addiction can decrease narcotic misuse and the risk of addiction.

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.

The efficacy of fascia iliaca compartment block for pain control after hip fracture: A meta-analysis

BACKGROUND

To assess the effect of fascia iliaca compartment block (FICB) on pain control and morphine consumption in patients with hip fracture.

METHODS

We searched databases (PubMed, Embase, Cochrane Library) for eligible randomized controlled trials (RCTs) published prior to September 12, 2018. We only included hip fracture patients who received FICB versus placebo for pain control. Risk ratios (RRs), standard mean differences (SMD) and 95% confidence intervals (CI) were determined. Stata 12.0 was used for the meta-analysis.

RESULTS

Eleven trials involving 937 patients underwent hip fracture were retrieved. FICB significantly decreased the pain intensity at 1-8 h (SMD = -1.03, 95% CI [-1.48, -0.58], P = .000), 12 h (SMD = -1.06, 95% CI [-1.36, -0.75], P = .000), 24 h (SMD = -1.14, 95% CI [-1.66, -0.62], P = .000) and 48 h (SMD = -0.96, 95% CI [-1.33, -0.60], P = .000). Moreover, FICB could reduced the total morphine consumption and the occurrence of nausea (P < .05). There was no significant difference between the pain intensity at 72 h (SMD = 0.11, 95% CI [-0.12, 0.34], P = .355).

CONCLUSIONS

FICB has a beneficial role in reducing pain intensity and morphine consumption after hip fracture. Moreover, FICB has morphine-sparing effects when compared with a control group. More high-quality RCTs are needed to identify the optimal technique and volume of injectate for FICB.