Femoral nerve block versus fentanyl: Analgesia for positioning patients with fractured femur

Ultrasound-guided pericapsular nerve group (PENG) block versus femoral nerve block for positioning during spinal anaesthesia in proximal femur fractures: A randomised comparative study

Background and Aims

Femoral nerve block is a widely used analgesia technique for positioning before spinal anaesthesia for proximal femur fracture surgeries. Pericapsular nerve group (PENG) block is a newer technique with motor-sparing characteristics. We compared the analgesic efficacy of these blocks for patient positioning for spinal anaesthesia.

Methods

In this study, 60 patients were randomised to either the PENG group (n = 30) or the femoral group (n = 30). After performing the block, the pain was assessed every 10 min using a visual analogue scale (VAS) score for 30 min. The primary objective was the median [interquartile range (IQR)] reduction in pain (dynamic VAS with 15-degree passive limb elevation) at 30 min. Secondary objectives were ease of spinal position score (EOSP), angle obtained during positioning, duration of postoperative analgesia and quadriceps weakness.

Results

The demographics were comparable in both groups. After 30 min, the median (IQR) VAS was 6 (5-7) in the PENG group and 5 (5-6) in the femoral group (P = 0.004). Secondary outcomes such as EOSP score and angle obtained by patients were comparable. In the postoperative period, patients had significantly lower pain in the PENG group compared to the femoral group. The duration of analgesia was prolonged with PENG block. Quadriceps weakness was significantly low with PENG block (P < 0.001).

Conclusion

PENG block provides better analgesia than a femoral block before spinal anaesthesia for proximal femur fracture surgery. The postoperative duration of analgesia was also longer.

Ultrasound-guided femoral nerve block and intravenous fentanyl in pain management of the patients with hip fracture: a prospective, randomized, single blinded clinical trial

Aim

Proximal femoral fracture is a painful condition. Pain alleviation is a treatment cornerstone to both comfort the patient and reduce adverse effects. This study aimed to evaluate and compare ultrasound‐guided femoral nerve block and intravenous fentanyl administration in relieving the pain of patients with hip fractures.

Methods

The present interventional clinical trial was conducted on 40 patients referred to Shahid‐Bahonar Hospital with unilateral isolated proximal femur fracture and American Society of Anesthesiologists I and II. The patients were randomly divided into two groups: intravenous fentanyl and ultrasound‐guided femoral nerve block for pain management. Pain severity was assessed by a numerical rating scale before and after the intervention in both groups and the groups were then compared.

Results

Forty patients were enrolled in to study; 27 (67.5%) were male. There was no significant difference in demographic variables between the two groups. Fourteen (35%) were older than 80 years. Pain significantly decreased three scores compared to the pre‐intervention level in both groups (95% confidence interval, 2–4). This was slightly higher in the femoral nerve block group. The largest strength of association for age and numerical rating scale of pain was found in the differences between the pre‐intervention and after‐intervention in femoral nerve block group (r = −0.775, P < 0.001).

Conclusion

We found similar pain severity between the two groups. Considering the possible side effects of fentanyl, an ultrasound‐guided femoral nerve block shows may provide safer pain control and may be particularly suitable for patients with opioid dependence.

Usefulness of ultrasonography guided femoral and lateral femoral cutaneous nerve blocks in providing analgesia before giving spinal anaesthesia in patients undergoing surgery for intertrochanteric fracture of femur: A randomized clinical trial

Background and Aims

It is challenging to give the patient position for subarachnoid block (SAB) as intertrochanteric (IT) fracture of the femur produces intolerable pain. In this study, we have analyzed the usefulness of combined ultrasonography (USG)-guided femoral nerve block (FNB) and lateral femoral cutaneous nerve block (LFCNB) to reduce the fracture pain before performing SAB.

Material and Methods

A prospective, randomized, comparative study was conducted on 60 American society of anesthesiologists (ASA) grade I and II patients (18-80 years) scheduled for elective IT fracture surgery. Group A (n = 30) patients received USG-guided FNB and LFCNB using 0.75% ropivacaine before SAB. Group B patients (n = 30) received SAB only. All the patients received SAB (3 mL of 0.5% bupivacaine) by an anesthesiologist blinded to the patient groups. The patients were observed for quality of patient positioning for SAB, perioperative visual analog scale (VAS) scores, time to administration of SAB, and duration of analgesia and motor blockade. Statistical analysis was done by Student's t-test and Chi-square test.

Results

Baseline VAS score (T1) was similar in both the groups. Mean T2 (VAS score just before SAB) in group-A (3.2 ± 0.98) was lower compared to group-B (8.23 ± 0.7) with P < 0.0001. The quality of patient positioning in group-A was good to optimal but in group-B, it was satisfactory to not satisfactory. Group-A had longer mean duration of analgesia 804 ± 114.28 minutes with P value < 0.0001 than group-B in which it was 200 ± 28.77 min. Backache was significant in group-B with P value of 0.038 compared to group-A.

Conclusion

USG-guided FNB and LFCNB can be used as an effective supplementation to SAB in patients undergoing surgery for IT fracture of the femur as it reduces fracture site pain, provides good patient positioning during SAB, and prolongs postoperative analgesia.

Dexmedetomidine as an adjuvant to 0.25% bupivacaine in ultrasound guided femoral nerve block for preoperative positioning and postoperative analgesia in patients undergoing elective surgery for fracture shaft of femur

Background:

Femur fracture causes excruciating pain and surgical repair is recommended. To obtain satisfactory patient co-operation in the perioperative period, various analgesics have been used. Femoral nerve block (FNB) provides an excellent alternative for analgesia in the perioperative period. Dexmedetomidine of up to 2 μg.kg⁻¹ has been used in FNB as adjuvants in lower limb surgeries.

Aims:

The aim was to study the effect of addition of Dexmedetomidine to Bupivacaine in FNB on the comfort of positioning for subarachnoid block (SAB) and postoperative analgesia.

Materials and Methods:

Prospective, randomized, double-blind design was followed. Seventy American Society of Anesthesiologist I and II patients aged 18–70 years of either gender were randomly allocated into Group B (20 mL 0.25% Bupivacaine + 2 mL Normal Saline) and Group BD (received 20 mL 0.25% Bupivacaine + Dexmedetomidine 2 μg.kg⁻¹ diluted to 2 mL) for FNB. Numerical rating scale (NRS) was recorded before and after FNB and comfort of positioning graded. After 10 min, subarachnoid block (SAB) was administered. NRS was recorded postoperatively until 24 h.

Results:

The comfort of positioning improved in both the groups after FNB but was statistically not significant when compared among the groups (P = 0.7). Duration of postoperative analgesia was significantly higher in the Group BD (741 min ± 97 min) compared to the Group B (440 min ± 45 min) (P = 0.001) and was statistically significant.

Conclusion:

FNB improved the comfort of positioning for SAB, but the addition of Dexmedetomidine did not have any added advantages with respect to comfort of positioning. However, the addition of Dexmedetomidine significantly increased the duration of postoperative analgesia with minimal hemodynamic changes.

Comparing Analgesic Effect of Intravenous Fentanyl, Femoral Nerve Block and Fascia Iliaca Block During Spinal Anesthesia Positioning in Elective Adult Patients Undergoing Femoral Fracture Surgery: a Randomized Controlled Trial

Background

Femoral fracture is the most painful bone injury and performing spinal anesthesia is extremely challenging due to very poor positioning unless we have a very good mode of analgesia. Intravenous strong opioids are commonly used but to date nerve blocks are also being utilized. The reliability and effectiveness of the aforementioned methods are not conclusive to practice worldwide. The objective of the study was to compare the analgesic effect of intravenous fentanyl, femoral nerve block (FNB) and fascia iliaca block (FICB) during positioning patients with femoral fracture for spinal anesthesia.

Methods

A randomized controlled trial study was conducted on 72 elective adult patients with femoral fracture aged 18–65 years and ASA I and II those were allocated randomly into three groups. The intravenous fentanyl (IVFE) group received 1µg/kg IV fentanyl, FNB group received nerve stimulator guided FNB with 30 mL of 1% lidocaine with adrenaline and FICB group received FICB with 30 mL of 1% lidocaine with adrenaline. Pain intensity in numeric rating score (NRS), time to perform spinal anesthesia, quality of positioning and patient acceptance were assessed. SPSS version 26 and Kruskal–Wallis test were used to analyze data and p value <0.05 was considered significant.

Results

NRS Pain score during positioning was significantly lower in FNB and FICB groups than IVFE group [median (IQR)]; 2 (1–2.5), 2 (2–3)) vs. 3 (3–4) respectively; P<0.001 and P=0.001. However, FNB and FICB groups were not significantly different with (P=1.000). Time to perform spinal anesthesia was significantly longer in IVFE group 9.5 (9–10) minutes than both FNB and FICB groups 7 (6–8), 8 (6–8) respectively, P<0.001. The quality of positioning was significantly lower in the IVFE group than both FNB and FICB groups (P<0.001).

Conclusion

Preoperative FNB and FICB reduce pain score during positioning, shorten time to perform spinal anesthesia, better patient positioning and higher patient acceptance in a patient undergoing elective femoral bone fracture surgery.

Trial Registration

Pan African Clinical Trial Registry, PACTR202006669166858, registered on June 19, 2020. https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12127.

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.

Analgesia for spinal anesthesia positioning in elderly patients with proximal femoral fractures: Dexmedetomidine-ketamine versus dexmedetomidine-fentanyl

Elderly patients with femoral fractures are anticipated to endure the most pain caused by positional changes required for spinal anesthesia. To improve pain relief, we compared the analgesic effects of intravenous dexmedetomidine-ketamine and dexmedetomidine-fentanyl combinations to facilitate patient positioning for spinal anesthesia in elderly patients with proximal femoral fractures. Forty-six patients were randomly assigned to two groups and received either 1 mg/kg of intravenous ketamine (group K) or 1 μg/kg of intravenous fentanyl (group F) concomitant with a loading dose of dexmedetomidine 1 μg/kg over 10 minutes, then dexmedetomidine infusion only was continued at 0.6 μg/kg/h for following 20 minutes, and titrated at a rate of 0.2 to 0.6 μg/kg/h until the end of surgery. After completion of the infusion of either ketamine or fentanyl, the patients were placed in the lateral position with the fracture site up. The pain score (0 = calm, 1 = facial grimacing, 2 = moaning, 3 = screaming, and 4 = unable to proceed because of restlessness or agitation) was used to describe the pain intensity in each step during the procedure (lateral positioning, hip flexion, and lumbar puncture), and quality score (0 = poor hip flexion, 1 = satisfactory hip flexion, 2 = good hip flexion, and 3 = optimal hip flexion) was used to describe the quality of posture. Group K showed a median pain score of 0 (0-1), 0 (0-0) and 0 (0-0) in lateral positioning, hip flexion and lumbar puncture, respectively, while group F showed a score of 3 (2.75-3), 3 (2-3) and 0 (0-1), respectively. The pain score in lateral positioning (P < .0001) and hip flexion (P < .0001) was significantly lower in group K than group F. Group K showed the significantly higher quality scores of spinal anesthesia positioning (P = .0044) than group F. Hemodynamic adverse effects, such as bradycardia, hypotension, and desaturation, were not significantly different between the groups. The administration of dexmedetomidine-ketamine showed a greater advantage in reducing pain intensity and increasing the quality with patient positioning during spinal anesthesia in elderly patients with proximal femoral fractures, without any serious adverse effects.

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.

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.

Efficacy and safety of femoral nerve block for the positioning of femur fracture patients before a spinal block - A systematic review and meta-analysis

Background

The evidence supporting the benefit of femoral nerve block (FNB) for positioning before spinal anesthesia (SA) in patients suffering from a femur fracture remains inconclusive. In the present study, the authors intended to determine the efficacy and safety of FNB versus an intravenous analgesic (IVA) for positioning before SA in patients with a femur fracture.

Method

PubMed, EMBASE, Cochrane, and Scopus databases were searched up to January 2018. We included randomized controlled studies (RCTs) and observational studies that compared FNB versus IVA for the positioning of patients with femur fracture receiving SA. The primary outcome was pain scores during positioning within 30 min before SA. Secondary outcomes were the time for SA, additional analgesic requirements, anesthesiologist’s satisfaction with the quality of positioning for SA, participant acceptance, and hemodynamic changes. A random-effects model was used to synthesize the data. We registered the study at PROSPERO with an ID of CRD42018091450.

Results

Ten studies with 584 patients were eligible for inclusion. FNB achieved significantly lower pain scores than IVA during positioning within 30 min before SA (pooled standardized mean deviation (SMD): -1.27, 95% confidence interval (CI): -1.84 to -0.70, p < 0.05). A subgroup analysis showed that the analgesic effect was larger in patients in the sitting position for SA than a non-sitting position (sitting position vs non-sitting: pooled SMD: -1.75 (p < 0.05) vs -0.61 (not significant). A multivariate regression showed that the analgesic effect was also associated with age and the total equivalent amount as lidocaine after adjusting for gender (age: coefficient 0.048, p < 0.05; total equivalent amount as lidocaine: coefficient 0.005, p < 0.05). Patients receiving FNB also had a significantly shorter time for SA, greater anesthesiologist satisfaction, and higher patient acceptance than patients receiving IVA. The use of local anesthetics did not produce significant clinical hemodynamic change.

Conclusion

Compared to IVA, FNB was an effective and safe strategy for the positioning of femur fracture patients for a spinal block, particularly patients who received SA in the sitting position.

Peripheral nerve blocks for hip fractures

BACKGROUND

Various nerve blocks with local anaesthetic agents have been used to reduce pain after hip fracture and subsequent surgery. This review was published originally in 1999 and was updated in 2001, 2002, 2009 and 2017.

OBJECTIVES

This review focuses on the use of peripheral nerves blocks as preoperative analgesia, as postoperative analgesia or as a supplement to general anaesthesia for hip fracture surgery. 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; 2016, Issue 8), MEDLINE (Ovid SP, 1966 to August week 1 2016), Embase (Ovid SP, 1988 to 2016 August week 1) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to August week 1 2016), as well as trial registers and reference lists of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) involving use of nerve blocks as part of the care provided for adults aged 16 years and older with hip fracture.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed new trials for inclusion, determined trial quality using the Cochrane tool and extracted data. When appropriate, we pooled results of outcome measures. We rated the quality of evidence according to the GRADE Working Group approach.

MAIN RESULTS

We included 31 trials (1760 participants; 897 randomized to peripheral nerve blocks and 863 to no regional blockade). Results of eight trials with 373 participants show that peripheral nerve blocks reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.41, 95% confidence interval (CI) -2.14 to -0.67; equivalent to -3.4 on a scale from 0 to 10; I² = 90%; high quality of evidence). Effect size was proportionate to the concentration of local anaesthetic used (P < 0.00001). Based on seven trials with 676 participants, we did not find a difference in the risk of acute confusional state (risk ratio (RR) 0.69, 95% CI 0.38 to 1.27; I² = 48%; very low quality of evidence). Three trials with 131 participants reported decreased risk for pneumonia (RR 0.41, 95% CI 0.19 to 0.89; I² = 3%; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 5 to 72; moderate quality of evidence). We did not find a difference in risk of myocardial ischaemia or death within six months, but the number of participants included was well below the optimal information size for these two outcomes. Two trials with 155 participants reported that peripheral nerve blocks also reduced time to first mobilization after surgery (mean difference -11.25 hours, 95% CI -14.34 to -8.15 hours; I² = 52%; moderate quality of evidence). One trial with 75 participants indicated that the cost of analgesic drugs was lower when they were given as a single shot block (SMD -3.48, 95% CI -4.23 to -2.74; moderate quality of evidence).

AUTHORS' CONCLUSIONS

High-quality evidence shows that regional blockade reduces pain on movement within 30 minutes after block placement. Moderate-quality evidence shows reduced risk for pneumonia, decreased time to first mobilization and cost reduction of the analgesic regimen (single shot blocks).

[Femoral nerve block versus intravenous fentanyl in adult patients with hip fractures - a systematic review]

BACKGROUND

Hip fractures configure an important public health issue and are associated with high mortality taxes and lose of functionality. Hip fractures refer to a fracture occurring between the edge of the femoral head and 5cm below the lesser trochanter. They are common in orthopedic emergencies. The number of proximal femoral fractures is likely to increase as the population ages. The average cost of care during the initial hospitalization for hip fracture can be estimated about US$ 7,000 per patient. Femoral fractures are painful and need immediate adequate analgesia. Treating pain femoral fractures is difficult because there are limited numbers of analgesics available, many of which have side effects that can limit their use. Opiates are the most used drugs, but they can bring some complications. In this context, femoral nerve blocks can be a safe alternative. It is a specific regional anesthetic technique used by doctors in emergency medicine to provide anesthesia and analgesia of the affected leg.

OBJECTIVE

To compare the analgesic efficacy of intravenous fentanyl versus femoral nerve block before positioning to perform spinal anesthesia in patients with femoral fractures assessed by Pain Scales.

METHODS

A systematic review of scientific literature was conducted. Studies described as randomized controlled trials comparing femoral nerve block and traditional fentanyl are included. Two reviewers (MR and FH) independently assessed potentially eligible trials for inclusion. The methodology assessment was based on the tool developed by the Cochrane Collaboration for assessment of bias for randomized controlled trials. The Cochrane Library, Pubmed, Medline and Lilacs were searched for all articles published, without restriction of language or time.

RESULTS

Two studies were included in this review. Nerve blockade seemed to be more effective than intravenous fentanyl for preventing pain in patients suffering from a femoral fracture. It also reduced the use of additional analgesia and made lower the risk for systemic complications. Femoral nerve block reduced the time to perform spinal anesthesia to the patient who will be subjected to surgery and facilitate the sitting position for this.

CONCLUSION

The use of femoral nerve block can reduce the level of pain and the need for additional analgesia. There are less adverse systemic events associated with this and the procedure itself does not offer greater risks. More studies are required for further conclusions.

Fascia iliaca block vs intravenous fentanyl as an analgesic technique before positioning for spinal anesthesia in patients undergoing surgery for femur fractures-a randomized trial

STUDY OBJECTIVE

Pain arising from femur fractures is of severe nature. Surgery for fixation of femoral fractures may be done under spinal anesthesia. We conducted this study to compare the analgesic efficacy of fascia iliaca compartment block (FICB) and intravenous fentanyl (IVF) before positioning for spinal anesthesia.

DESIGN

Randomized controlled trial.

SETTING

Operating room.

PATIENTS AND INTERVENTIONS

Sixty patients aged 25 to 75 years, with American Society of Anesthesiologists status I to III, undergoing surgery for femur fracture were chosen for the study and randomized into 2 groups. Patients in group FICB received the block with 30 mL of 0.375% ropivacaine 15 minutes before the subarachnoid block. Patients in group IVF received intravenous fentanyl at 0.5 μg/kg body weight repeated up to a maximum of 3 doses. Spinal was administered using 12 to 15 mg of 0.5% hyperbaric bupivacaine with glucose 80 mg/mL in patients of both groups.

MEASUREMENTS

Preprocedural and postprocedural parameters such as visual analog scale (VAS) scores, sitting angle, quality of positioning, and time to perform the spinal were recorded. Patients were also assessed in the first 24 hours for analgesic requests.

MAIN RESULTS

Preprocedural VAS scores were similar in both groups. The "VAS after" was 24.72±15.70 mm in group FICB vs 61.22±18.18 mm in group IVF (P=.01). The drop in VAS scores was significantly more in the FICB group. Sitting angle improved significantly in the FICB group. (56.17°±16.54° vs 21.38°±23.90°; P=.01). Patients in group FICB also needed less time for spinal and had better quality of positioning. Postoperative analgesic requirement was lesser in group FICB.

CONCLUSION

Fascia iliaca block offers superior analgesia compared to IVF in patients with femur fracture before positioning for spinal anesthesia.

Analgesic Efficacy of Ultrasound Guided FICB in Patients with Hip Fracture

INTRODUCTION

Hip fractures are often encountered in the elderly and present special problems to the anaesthesiologist. Fascia iliaca compartment block is another technique with the intent to block all the three nerves like 3-in-1 nerve block.

AIM

To evaluate the analgesic efficacy of ultrasound guided fascia iliaca compartment block to facilitate positioning of patients with hip fracture for spinal anaesthesia.

MATERIALS AND METHODS

This prospective study was conducted in 50 patients aged between 40-80 years, belonging to American Society of Anesthesiologists (ASA) physical status I-III undergoing surgery for hip fracture. All 50 patients received an ultrasound guided Fascia Iliaca Compartment Block (FICB) in the premedication room with 30 mL of 0.5% ropivacaine by 23G spinal needle. Sensory blockade was evaluated 5, 10 and 20 minutes after ropivacaine administration using loss of perception to cold in the lateral, anterior and medial part of the thigh. Visual analogue scale scores were noted before the block, 20 minutes after block and during positioning for spinal anaesthesia. Patient's acceptance for FICB was evaluated 24 hour after arriving back to the orthopaedics ward using a two-point score. Any episode of hypotension or bradycardia was noted and managed accordingly.

RESULTS

In lateral part of thigh, at 5 minutes sensory blockade was present in 33 patients (66%) and at 10 minutes sensory blockade was present in 45 cases (90%). In anterior part of thigh, sensory blockade was present in 34 cases (68%) at 5 minutes time interval and at 10 minutes sensory blockade was present in 48 cases (96%). In medial part of thigh, 28 cases (56%) had sensory blockade at 5 minutes and at 10 minutes in 43 cases (86%). Sensory blockage was same at 20 minutes as on 10 minutes interval in all thigh parts. Before FIC block average VAS was 7.5 which was decreased to average of 2.94 at 20 minutes after block which was statistically significant (p<0.01). During positioning for spinal anaesthesia, 46 patients had VAS less than 4. Positioning during spinal anaesthesia was assessed unsatisfactory (0) in 2 cases (4%), satisfactory (1) in 5 cases (10%), good (2) in 25 cases (50%) and excellent (3) in 18 cases (36%).

CONCLUSION

Ultrasound guided FICB can be performed safely without complications in controlling pain for patients with hip fracture. Performing an FICB before positioning for spinal anaesthesia provides good pain management and facilitates spinal performance with wide patient acceptance, hence improving overall quality and efficiency of care.

Intravenous analgesia with opioids versus femoral nerve block with 0.2% ropivacaine as preemptive analgesic for fracture femur: A randomized comparative study

BACKGROUND AND OBJECTIVE

Femoral fractures are extremely painful and pain invariably worsens on any movement. Anesthesia for fracture femur surgery is usually provided by spinal block. This study was undertaken to compare the analgesic effects of femoral nerve block (FNB) using nerve stimulator with 0.2% ropivacaine (15 ml) and intravenous (I.V.) fentanyl before patient positioning for fracture femur surgery under spinal anesthesia.

MATERIALS AND METHODS

A prospective, randomized, double-blind, comparative study was conducted on 60 American Society of Anesthesiologists I and II patients (18-60 years) scheduled for femur surgery under combined spinal epidural anesthesia. Patients in Group I (n = 30), were administered FNB using nerve stimulator with 0.2% ropivacaine (15 ml) and in Group II patients (n = 30), I.V. fentanyl 0.5 μg/kg was given as preemptive analgesia. Parameters observed included time to spinal anesthesia, intra-operative and postoperative visual analog scale (VAS) for any pain and postoperative epidural top-ups dosages.

RESULTS

Demographic profile was comparable in both the groups. VAS at 2 min in Group I was 5.63 and in Group II it was 8.00. Satisfaction score was better in Group I as compared to Group II patients. Time to administer subarachnoid block was 17.80 min in patients of Group I as compared to 25.03 min in Group II patients. Postoperatively, VAS scores were lower in Group I than Group II patients. The frequency of epidural top-ups was higher in Group II than in Group I patients.

CONCLUSIONS

FNB is comparatively better in comparison to I.V. fentanyl when used as preemptive and postoperative analgesic in patients being operated for fracture femur.

Femoral nerve block versus intravenous fentanyl in adult patients with hip fractures - a systematic review

BACKGROUND

Hip fractures configure an important public health issue and are associated with high mortality taxes and lose of functionality. Hip fractures refer to a fracture occurring between the edge of the femoral head and 5cm below the lesser trochanter. They are common in orthopedic emergencies. The number of proximal femoral fractures is likely to increase as the population ages. The average cost of care during the initial hospitalization for hip fracture can be estimated about US$ 7,000 per patient. Femoral fractures are painful and need immediate adequate analgesia. Treating pain femoral fractures is difficult because there are limited numbers of analgesics available, many of which have side effects that can limit their use. Opiates are the most used drugs, but they can bring some complications. In this context, femoral nerve blocks can be a safe alternative. It is a specific regional anesthetic technique used by doctors in emergency medicine to provide anesthesia and analgesia of the affected leg.

OBJECTIVE

To compare the analgesic efficacy of intravenous fentanyl versus femoral nerve block before positioning to perform spinal anesthesia in patients with femoral fractures assessed by Pain Scales.

METHODS

A systematic review of scientific literature was conducted. Studies described as randomized controlled trials comparing femoral nerve block and traditional fentanyl are included. Two reviewers (MR and FH) independently assessed potentially eligible trials for inclusion. The methodology assessment was based on the tool developed by the Cochrane Collaboration for assessment of bias for randomized controlled trials. The Cochrane Library, Pubmed, Medline and Lilacs were searched for all articles published, without restriction of language or time.

RESULTS

Two studies were included in this review. Nerve blockade seemed to be more effective than intravenous fentanyl for preventing pain in patients suffering from a femoral fracture. It also reduced the use of additional analgesia and made lower the risk for systemic complications. Femoral nerve block reduced the time to perform spinal anesthesia to the patient who will be subjected to surgery and facilitate the sitting position for this.

CONCLUSION

The use of femoral nerve block can reduce the level of pain and the need for additional analgesia. There are less adverse systemic events associated with this and the procedure itself does not offer greater risks. More studies are required for further conclusions.

Preoperative fascia iliaca compartment block for positioning patients with hip fractures for central nervous blockade: a randomized trial

BACKGROUND AND OBJECTIVES

Appropriate pain management may positively affect outcome following hip fractures. Positioning patients for spinal anesthesia (SA) can be extremely painful. Peripheral nerve blockades are gaining popularity in this setting. This prospective, randomized study compares the efficacy of fascia iliaca compartment block (FICB) to intravenous (IV) fentanyl for positioning hip fracture patients for SA.

METHODS

Forty-one patients scheduled for hip fracture surgery were randomized to receive a bolus dose of IV fentanyl (IVFE) 1.5 μg/kg (IVFE group) or an FICB using 40 mL ropivacaine 0.5% (FICB group) 5 or 20 minutes before positioning for SA, respectively. Numeric rating pain scale scores before and following the analgesic intervention, time needed and quality of patient position for SA performance, postoperative analgesia in terms of time to first IV morphine dose demand and morphine consumption during the first 24 hours, and patient satisfaction were documented.

RESULTS

Compared with the IVFE group, the FICB group showed significantly lower numeric rating pain scale scores in all instances following the analgesic intervention (P < 0.001), shorter spinal performance time (P = 0.001), and better quality of position (P = 0.001). Postoperative morphine consumption was lower (P = 0.026), the time to first dose demand was longer (P = 0.001), and patient satisfaction rates were higher (P < 0.001) in the FICB group.

CONCLUSIONS

Performing an FICB before positioning for SA provides superior pain management compared with IVFE administration, facilitates spinal performance, and yields satisfactory postoperative analgesia and wide patient acceptance, hence improving overall quality and efficiency of care.

Comparative evaluation of femoral nerve block and intravenous fentanyl for positioning during spinal anaesthesia in surgery of femur fracture

BACKGROUND

Spinal anaesthesia is the preferred technique to fix fracture of the femur. Extreme pain does not allow ideal positioning for this procedure. Intravenous fentanyl and femoral nerve block are commonly used techniques to reduce the pain during position for spinal anaesthesia however; results are conflicting regarding superiority of femoral nerve block over intravenous fentanyl.

AIMS

We conducted this study to compare the analgesic effect provided by femoral nerve block (FNB) and intra- venous (IV) fentanyl prior to positioning for central neuraxial block in patients undergoing surgery for femur fracture.

PATIENTS AND METHODS

In this randomized prospective study 60 patients scheduled for fracture femur operation under spinal were included. Patients were distributed in two groups through computer generated random numbers table; Femoral nerve block group (FNB) and Intravenous fentanyl group (FENT). In FNB group patients received FNB guided by a peripheral nerve stimulator (Stimuplex; B Braun, Melsungen, AG) 5 minutes prior to positioning. 20mL, 1.5% lidocaine with adrenaline (1:200,000) was injected incrementally after a negative aspiration test. Patients in the fentanyl group received injection fentanyl 1 μg/kg IV 5 mins prior to positioning. Spinal block was performed and pain scores before and during positioning were recorded. Statistical analysis was done with Sigmaplot version-10 computer software. Student t-test was applied to compare the means and P < 0.05 was taken as significant.

RESULTS

VAS during positioning in group FNB: 0.57 ± 0.31 versus FENT 2.53 ± 1.61 (P = 0.0020). Time to perform spinal anesthesia in group FNB: 15.33 ± 1.64 min versus FENT 19.56 ± 3.09 min (P = 0.000049). Quality of patient positioning for spinal anesthesia in group FNB 2.67± 0.606 versus FENT 1.967 ± 0.85 (P = 0.000027). Patient acceptance was less in group FENT (P = 0.000031).

CONCLUSION

Femoral nerve block provides better analgesia, patient satisfaction and satisfactory positioning than IV fentanyl for position during spinal anaesthesia in patients of fracture femur.