Fascia iliaca compartment block

Regional anesthesia for hip surgery: A review of current approaches and their application to clinical practice

Hip surgery is extremely common and ranges from surgery for hip fracture to elective procedures in younger adults. Pain can mark the postoperative period and compromise functional recovery. Nevertheless, major comorbidities may occur in the perioperative period, especially in elderly fragile patients. The approach to patients undergoing hip surgery has significantly evolved, focusing on multimodal strategies to optimize pain control while minimizing side effects, prompting patients' recovery. The seek for motor-sparing, analgesic techniques with a better risk benefit profile has promoted the application of new peripheral nerve blocks, with special attention paid to the newest fascial plane blocks. However, significant interest is addressed toward other outcomes (such major comorbidities and deaths) that may influence intermediate and long-term recovery. Specific strategies have been investigated to improve outcomes after hip surgery in elderly patients, considering the higher risk for complications, including delirium. In this narrative review, we aim to summarize the role of regional anesthesia and analgesia in the context of hip surgery by detailing on the effects of regional anesthesia on major outcomes. Considering the specific innervation of hip joint, we summarize the available evidence on newer peripheral nerve blocks for hip patients by focusing on potential complications associated with each technique, especially the occurrence of motor block. In this review, we aim to provide an updated and concise overview of the available evidence to help the reader planning the most appropriate strategy for hip surgery.

Combining Immersive Simulation with a Collaborative Procedural Training on Local Anesthetic Systemic Toxicity and Fascia Iliaca Compartment Block: A Pilot Study

Introduction

Readiness to perform a wide variety of procedures or manage nearly any patient presentation remains an essential aspect of emergency medicine training and practice. Often, simulation is needed to supplement real-life exposure to provide comfort and knowledge, particularly with rarer pathology and procedures. As the scope of practice continues to grow, newer procedures, such as ultrasound (US)-guided nerve blocks (UGNB), are becoming integrated into resident training, building on previously established skills. The fascia iliaca compartment block (FICB) is performed on patients with specific femoral fractures and is a now a component of standard multimodal pain regimens, with US-guidance limiting adverse events. Given the need for high volumes of local anesthetic to perform the block it is imperative for clinicians to understand dosing as well as recognize and treat local anesthetic systemic toxicity (LAST). With sparse literature on sequential immersive and procedural simulation involving intertwined topics, this presents a unique opportunity for learners.

Methods

To study the perceived knowledge and comfort with FICB and LAST, a pilot study was developed with two separate but concurrent one-hour simulations completed encompassing one of each topic over one day. We surveyed 19 learners, consisting of residents ranging from postgraduate years 1-3, prior to and immediately following completion, regarding their perceptions. We used the Stuart-Maxwell test to compare survey data.

Results

More than half of participants (56%) had not received prior formal training on FICB. There was a positive trend in perceived confidence and knowledge with visualizing relevant anatomy (4.0 [2.0-6.0] vs 9.0 [7.5-10.0], P = 0.10), performing FICB (4.0 [1.0-5.0] vs 9.0 [7.0-10.0, P = 0.08]), and perceived ability to teach their peers (3.0 [1.0-5.0] vs 8.5 [7.0-10.0], P = 0.20). Perceived ability in diagnosing and managing LAST also increased following the simulation (5.0 [3.0-6.0] vs 6.0 [6.0-7.0], P = 0.12 and 3.0 [2.0-6.0] vs 6.0 [6.0-7.0], P = 0.08, respectively).

Conclusion

Learners' perceptions of this simulation experience echo the findings of previous studies in which simulation can be used to teach procedures and pathology; of note, however, we presented a novel experience with a combination of immersive and procedural simulation.

Acute hip fractures and the fascia iliaca compartment block

ABSTRACT

Acute hip fractures are common injuries evaluated in the ED. Emergency medicine clinicians are tasked with managing patients' severe pain while also trying to reduce harm caused by overuse of opioids. Multimodal analgesics, including peripheral nerve blocks, are crucial to pain management. This article reviews the fascia iliaca compartment block and the benefits of its early use.

Suprainguinal fascia iliaca compartment block in pediatric-aged patients: An educational focused review

Regional anesthesia has become an integral component of postoperative analgesia and multimodal analgesia during surgery, providing opioid sparing effects and maintaining a beneficial adverse effect profile. Although neuraxial techniques were initially the primary techniques used for intraoperative and postoperative anesthesia and analgesia, many of these techniques have been replaced by selective nerve blockade. This has been facilitated by the widespread use of ultrasound-guided over conventional landmark techniques. Fascia iliaca compartment blockade (FICB) is performed by depositing a local anesthetic agent underneath the FI fascial sheath which lies on top of the iliopsoas muscle. With the landmark technique, the FICB is more commonly applied using an approach below the inguinal ligament. Advancements in the use of ultrasound have led to development of a potentially superior suprainguinal fascia iliaca (SIFI) block for hip and thigh surgery. An improved cephalad distribution of the local anesthetic solution within the fascia iliaca compartment and comparable analgesic efficacy compared to the more invasive lumbar plexus block has resulted in increased use of the SIFI block in both adults and pediatric-aged patients. The SIFI block aims to target the femoral nerve (FN), lateral femoral cutaneous nerve (LFCN), and obturator nerve (ON), thus providing analgesic coverage for hip, femur, and thigh surgery. Although the FN and LFCN are reported to be consistently blocked by the suprainguinal approach, blockade of the ON may be less reliable and requires a higher volume of the local anesthetic agent, proving this technique to be a volume-dependent block. A lower volume of local anesthetic solution may be associated with block failure, especially in the area supplied by the ON and less frequently in the distribution of the LFCN. Thus, local anesthetic concentration must be adjusted in smaller children and infants to maintain effective volume while not exceeding local anesthetic dosing limitations. The current manuscript reviews the innervation of the lower extremity including the anatomy of the fascia iliaca compartment, outlines different approaches for the fascia iliaca block, and reviews the current practice of SIFI blockade in adults and children.

Continuous Suprainguinal Fascia Iliaca Block for Postoperative Analgesia Management After Hip and Knee Arthroplasty Surgeries: A Report of Two Cases

Knee and hip arthroplasty are common orthopedic procedures that are frequently associated with moderate to severe postoperative pain. Regional anesthesia techniques play a crucial role in multimodal analgesia strategies for managing postoperative pain. The suprainguinal fascia iliaca (SIFI) block is an effective regional anesthesia technique frequently used for postoperative analgesia in lower extremity surgeries, including knee and hip arthroplasty. These techniques can be safely applied either as a single-shot injection or via continuous catheter insertion. In this case report, we describe our experience with the use of continuous SIFI block for postoperative analgesia in knee and hip arthroplasty.

Supra-inguinal fascia iliaca block versus peri-capsular nerve group (PNEG) block for pain management in patients with hip fracture: A double-blind randomised comparative trial

BACKGROUND

Regional analgesia has been recommended to alleviate pain caused by hip fractures. Both the supra-inguinal fascia iliaca block (S-FIB) and the peri‑capsular nerve group (PENG) block provide better analgesia than conventional fascia iliaca block for patients with hip fractures, but which one is superior remains equivocal. This study aimed to determine the superiority of S-FIB or PENG block for patients awaiting hip surgery.

METHODS

In this prospective, double-blind, randomised comparative trial, patients with hip fractures awaiting operation were randomly allocated to receive either S-FIB with 30 ml 0.35 % ropivacaine or PENG block with 20 ml 0.35 % ropivacaine. Primary outcomes were pain scores (numeric rating scale, NRS, 0-10) at rest and during passive movement 30 min after nerve block. Secondary outcomes included pain scores at rest and during movement 10 and 20 min after nerve block and during positioning for spinal anaesthesia, time spent for performing nerve block and spinal anaesthesia, and the quality of positioning for spinal anaesthesia.

RESULTS

One-hundred patients were enrolled and 91 patients completed the trial (S-FIB group n = 46, PENG group n = 45). No significant difference was noted between these two groups in the pain scores (median [interquartile range]) either at rest (0 [0-0] vs 0 [0-0], P = 0.151) or during passive movement (3 [1-6] vs 3 [2-5], P = 0.99) at 30 min after nerve block. However, within-group analysis revealed that a significant reduction in pain score at rest was noted as early as 20 min after PENG block while that was noted only at 30 min after S-FIB. In addition, less time was required to perform PENG than S-FIB the block (3.1 [2.3-3.9] vs. 4.6 [3.1-5.6] minutes, P < 0.001).

CONCLUSIONS

Our result suggests that with a lower dose of local anaesthetic, a shorter procedure time and earlier analgesic effect, PENG block may be preferred to S-FIB for patients with hip fracture awaiting surgery.

Assessing the Clinical Impact of Emergency Physician-performed Ultrasound-guided Peripheral Nerve Blocks in a Level 1 Trauma Center: A Retrospective Analysis

Introduction

Effective pain management is crucial in the emergency department (ED), particularly for trauma patients. Ultrasound-guided regional analgesia (UGRA) has emerged as a promising technique for acute pain relief. The objective of this study is to describe the various UGRA performed and assess their effectiveness among trauma patients in our Level 1 Trauma Center ED over the past 2.5 years.

Methods

Data from 485 trauma patients who underwent UGRA over 2.5 years were analyzed retrospectively. The primary outcome was the median Defense and Veterans Pain Rating Scale (DVPRS) reduction at 30 min and 1 h after nerve block administration. Patient characteristics, types of nerve blocks administered, procedural details, and outcomes were also noted. Statistical analysis was performed to determine the median reduction in pain scores and evaluate the success of UGRA.

Results

UGRA demonstrated a significant reduction in pain scores, with a median DVPRS decrease from 9 (interquartile range [IQR]: 9-10) preprocedure to 4 (IQR: 2-5) at 30 min and 1 (IQR: 0-2) at 1 h postprocedure. Sixteen types of nerve blocks were administered in our ED, with the serratus anterior block (n = 91) and fascia iliaca compartment block (n = 58) being the most common. Pain relief was the most common indication for block administration. A higher volume was injected for plane blocks compared to nerve-specific blocks. No complications or failed blocks were reported.

Conclusion

This study describes 16 different UGRA that can be performed by emergency physicians (EPs) in ED for trauma patients. UGRA is effective in providing substantial pain relief for trauma patients in the ED. UGRA performed by EPs offers a safe and feasible approach for managing acute pain in the ED.

Fascia Iliaca Catheters for Donor Site Pain After Split-Thickness Skin Grafting for Acute Burn Injury: A Retrospective Review

The management of acute burn pain poses significant challenges. Regional techniques have become increasingly popular in perioperative burn pain management. Continuous nerve block catheters are particularly useful for split-thickness skin grafts where donor site pain can exceed that of the burn-injured site. Donor skin is frequently harvested from the anterolateral thigh. The fascia iliaca (FI) compartment block provides blockade of both the lateral femoral cutaneous nerve and the femoral nerve, and thus, it is a useful modality for burn donor pain. Our institution initiated a protocol in which continuous FI catheters were placed in patients undergoing split-thickness skin grafting of the anterolateral thigh. This retrospective review seeks to assess the impact of this modality on postoperative pain scores and opioid requirements. Oral morphine equivalent (OME) administration was significantly lower in the FI group than the control group, starting with POD 0, which is the day of the FI catheter insertion (188 vs 327 mg, P < .001). Over the next 4 postoperative days (PODs), OME administration remained lower in the FI group compared to control patients, although not statistically significant on PODs 3-4. There was a significant difference in OME administered between the FI group and the control group on POD 5 (159.5 vs 209.2 mg, P < .05). Our retrospective study evaluating the role of FI catheters in burn patients undergoing split-thickness skin grafting surgery showed significantly lower opioid consumption on PODs 1-5 compared to patients without an FI catheter.

Ultrasound-Guided Suprainguinal Fascia Iliaca Compartment Block in Patients Undergoing Hip Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The use of fascia iliaca compartment block (FICB) has been widely encouraged for hip surgery; however, meta-analyses showed mixed results in terms of its efficacy in reduction in analgesic consumption and pain score. These meta-analyses included all forms of FICB approaches, which may diminish the effect size of the therapy. Suprainguinal FICB (s-FICB) has been shown to be superior to other FICB approaches including the ultrasound-guided infrainguinal approach and the landmark approach. This systematic review and meta-analysis aim to compare opioid consumption, pain score, and complications after s-FICB to control for patients undergoing hip surgery. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42023460377). We performed a systematic literature search in Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases from inception to 16 August 2023 to identify randomized controlled trials (RCTs) that evaluated the efficacy of s-FICB versus control for patients undergoing hip surgery. Data were independently extracted by two reviewers, and disagreements were resolved by consensus or by discussion with a third investigator. The primary outcome is the 24-hour oral morphine equivalent daily dose (oMMED). The secondary outcome includes oMMED at different timepoints, and pain score. The Cochrane risk of bias tool (Cochrane, London, England) was used to assess the risk of bias. The certainty of evidence was assessed via the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Data were synthesized using a random-effects model. Trial sequence analysis is performed on opioid consumption 24 hours post operation. Eleven randomized controlled trials were included. Arthroscopic hip surgery was performed in three studies involving 222 patients, hip and femur fracture surgeries were performed in three studies involving 149 patients, and total hip arthroplasty was performed in five studies involving 483 patients. In studies involving arthroscopic hip surgery, s-FICB did not improve intra-operative and post-operative opioid consumption and post-operative pain score. In studies involving hip and femur fracture surgeries, s-FICB was associated with a non-significant difference in opioid consumption at 24 hours after surgery and post-operative pain score at 12 hours and 24 hours after surgery. However, the result of the trial sequential analysis (TSA) was not definitive, indicating that additional research is necessary to draw conclusive outcomes. In studies involving total hip arthroplasty, s-FICB was associated with a significant reduction in post-operative opioid consumption at 24 and 48 hours with conclusive results in trial sequential analysis. In conclusion, s-FICB is superior to placebo for patients undergoing total hip arthroplasty. For patients undergoing arthroscopic hip surgery, s-FICB is unlikely to be beneficial. With regard to hip fracture surgery, additional research is necessary to draw conclusive outcomes.

Comparison of Dye Spread Pattern and Nerve Involvement between Suprainguinal and Infrainguinal Fascia Iliaca Blocks with Different Injectate Volumes: A Cadaveric Evaluation

Background and Objectives: Fascia iliaca compartment block (FICB) is an effective and relatively safe technique in perioperative pain management for hip surgery. However, blockade of the obturator nerve (ON) using this technique remains controversial. This study aimed to compare dye spread patterns and nerve involvement in the suprainguinal FICB (S-FICB) and infrainguinal FICB (I-FICB) approaches using different volumes of dye. Materials and Methods: Following randomization, 6 S-FICBs and 6 I-FICBs were performed on the left or right sides of 6 unembalmed cadavers. For each block, 30 mL or 60 mL of dye solution was injected. The extent of dye spreading and the staining pattern in the lumbar plexus branches were investigated using anatomical dissection. Results: Twelve injections were successfully completed. The lateral femoral cutaneous nerve (LFCN) and femoral nerve (FN) were consistently stained in all injections. Extended dye spread toward lumbar plexus branches was observed volume-dependently in S-FICBs. However, I-FICBs with an increased volume only showed dye spreading in the caudad direction limited to within the fascia iliaca. When 30 mL of dye was used, the ON was not stained with either approach. A stained ON was only observed in S-FICBs when 60 mL of dye was used. Conclusions: In this cadaveric evaluation, the ON was not stained in either FICB approach with the volume of injectate commonly used in clinical practice. The S-FICBs but not I-FICBs using a high volume of injectate resulted in extended spreading to the lumbar plexus branches.

Comparative analysis of perioperative outcomes in endovascular abdominal aortic aneurysm repair: Fascia iliaca block versus general anesthesia, a retrospective study

OBJECTIVE

This retrospective study aimed to compare rates of perioperative mortality and morbidity, especially pulmonary complication, between endovascular aneurysm repair (EVAR) performed under general anesthesia (GA) and under fascia iliaca block (FIB).

METHODS

Patients diagnosed with infrarenal abdominal aortic aneurysm (AAA) who were treated with EVAR were included. Retrospective review of electronic medical records was performed. Patient characteristics, operative details, and postoperative results including mortality and morbidity within 30 days were collected. Statistical analysis to compare postoperative outcomes between EVAR under FIB and EVAR under GA was performed. A univariate analysis was conducted to identify factors associated with increased 30-day mortality.

RESULTS

This study included 119 patients, 75 in the FIB group and 44 in the GA group. Most patients were male, with 62 (82.5%) in the FIB group and 31 (70.2%) in the GA group, and most patients were hypertensive, with 57 (76%) in the FIB group and 36 (81.8%) in the GA group. Smoking and coronary artery disease (CAD) was more prevalent in the FIB group, p < .05. Thirty-day mortality was not significantly different between the FIB group and the GA group (1 (1.3%) vs 2 (4.5%), p = .554). Pulmonary complication was lower in the FIB group than in the GA group (1.3% vs 11.4%, p = .026). ICU stay was shorter in the FIB group than in the GA group (0.2 vs 4.5 days, p = .012). Univariate analysis showed that chronic obstructive pulmonary disease (COPD) was associated with higher 30-day mortality.

CONCLUSIONS

Endovascular aneurysm repair under FIB was feasible. Compared to GA, this approach resulted in lower postoperative pulmonary complications and shorter ICU stay.

Comparing the Efficacy of Landmark-Based Fascia Iliaca Compartment Block and Pericapsular Nerve Group Block for Preoperative Positioning and Postoperative Analgesia in Patients Undergoing Surgery for Hip Fractures: A Randomized Controlled Trial

BACKGROUND

Subarachnoid block is the most common anesthetic technique for patients having corrective hip surgeries. However, adequate positioning for a successful subarachnoid block is a major challenge in this particular population of patients, owing to the site of fracture. Regional anesthesia, in the form of nerve blocks, is an effective means of alleviating such constraints and gives an added benefit of prolonged postoperative analgesia. The pericapsular nerve group (PENG) block and the fascia iliaca compartment block (FICB), under ultrasonography guidance, are a few examples of the commonly performed peripheral nerve blocks in such settings. However, the landmark-based techniques of nerve blockade still hold good in many resource poor settings, given the lack of ultrasonography facilities.

AIM

To compare the ease of spinal positioning using the patient sitting satisfaction score between the landmark-guided FICB and PENG block.

MATERIALS AND METHODS

This study was done on 80 patients of the American Society of Anesthesiology (ASA) grade I or II with intertrochanteric fractures of the hip joint scheduled for proximal femoral nailing. Patients were allocated into two groups of 40 each through computer generated random numbers, to receive 30 ml of 0.5% ropivacaine via the landmark-guided technique of FICB in Group F and peripheral nerve stimulator assisted landmark-guided PENG block in Group P, 30 minutes prior to spinal positioning. Time to passive leg raise (PLR) to 15 degrees and time to PLR to 30 degrees with a standard goniometer guidance at visual analogue scale (VAS) score < 4 and ease of spinal positioning through the sitting satisfaction score at the 30th minute were assessed. Any adverse effects and events of failure were noted. The duration of postoperative analgesia was measured through the time to the first dose of paracetamol on arrival at the post-anesthesia care unit.

RESULTS

Statistical analysis was done using JASP version (0.18.3.0) using the independent samples t-test and significance was taken when p value was < 0.001. The time to PLR to 15 degrees and 30 degrees were achieved faster in the patients who received the PENG block in comparison to the patients who received the FICB, and the average patient sitting satisfaction score was significantly higher in Group P as compared to Group F (p < 0.001). While the overall amount of analgesics used in both groups was similar, the overall period of postoperative analgesia was prolonged in Group F compared to Group P (p < 0.001).

CONCLUSION

The landmark guided PENG block is feasible and superior to the landmark-guided FICB for preoperative positioning and analgesia. The FICB provides a longer duration of postoperative analgesia for patients with intertrochanteric fractures.

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

OBJECTIVES

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

METHODS

DESIGN

Prospective cohort study.

SETTING

Community-based Level 1 trauma center.

PATIENT SELECTION CRITERIA

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

OUTCOME MEASURES AND COMPARISONS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Regional Anesthesia in the Austere Environment: Lessons Learned from Current Out-of-Hospital Practice

INTRODUCTION

Pain management for trauma in the extreme environment is vital for both casualty comfort and aiding safe extrication. However, adequate pain management in a resource-limited environment can be challenging and is often limited. We conducted a scoping review of the use of regional anesthesia in the prehospital environment, evaluating which regional anesthetic procedure was performed for various indications, their efficacy, and the type of healthcare provider delivering the anesthetic.

METHODS

A PRISMA-guided systematic literature review was conducted of Medline, Embase, and Cochrane databases for studies reporting the use of regional anesthesia in the prehospital environment published before June 30, 2022.

RESULTS

Thirty studies met the criteria and were included in the review. The most common types of regional anesthesia were fascia-iliaca compartment block (n = 317, from 12 studies) and femoral nerve block (n = 210, from 8 studies), along with various other blocks for a range of indications. These blocks had good efficacy and a low-risk profile and could be delivered by a wide range of healthcare providers.

CONCLUSIONS

Regional anesthesia is an effective and non-resource-heavy pain management tool in prehospital environments, which may be applicable to austere settings. It can cover a wide range of injuries and can avoid systemic complications for casualties that may already be challenging to manage in out-of-hospital settings. Additionally, regional anesthesia can be effectively delivered by a wide range of providers. This review provides a holistic summary of pain management using regional anesthesia in the prehospital environment, with a discussion on its potential use in more extreme settings.

Development and validation of an assessment tool for adult simulated ultrasound-guided fascia iliaca block: a prospective monocentric study

BACKGROUND

Fascia iliaca block (FIB) is an effective technique for analgesia. While FIB using ultrasound is preferred, there is no current standardised training technique or assessment scale. We aimed to create a valid and reliable tool to assess ultrasound-guided FIB.

METHOD

This prospective observational study was conducted in the ABS-Lab simulation centre, University of Poitiers, France between 26-29 October and 14-17 December 2021. Psychometric testing included validity analysis and reliability between two independent observers. Content validity was established using the Delphi method. Three rounds of feedback were required to reach consensus. To validate the scale, 26 residents and 24 emergency physicians performed a simulated FIB on SIMLIFE, a simulator using a pulsated, revascularised and reventilated cadaver. Validity was tested using Cronbach's α coefficient for internal consistency. Comparative and Spearman's correlation analysis was performed to determine whether the scale discriminated by learner experience with FIB and professional status. Reliability was analysed using the intraclass correlation (ICC) coefficient and a correlation score using linear regression (R2).

RESULTS

The final 30-item scale had 8 parts scoring 30 points: patient positioning, preparation of aseptic and tools, anatomical and ultrasound identification, local anaesthesia, needle insertion, injection, final ultrasound control and signs of local anaesthetic systemic toxicity. Psychometric characteristics were as follows: Cronbach's α was 0.83, ICC was 0.96 and R2 was 0.91. The performance score was significantly higher for learners with FIB experience compared with those without experience: 26.5 (22.0; 29.0) vs 22.5 (16.0; 26.0), respectively (p=0.02). There was a significant difference between emergency residents' and emergency physicians' scores: 20.5 (17.0; 25.0) vs 27.0 (26.0; 29.0), respectively (p=0.0001). The performance was correlated with clinical experience (Rho=0.858, p<0.0001).

CONCLUSION

This assessment scale was found to be valid, reliable and able to identify different levels of experience with ultrasound-guided FIB.

Pericapsular nerve group block and lateral femoral cutaneous nerve block versus fascia iliaca block for multimodal analgesia after total hip replacement surgery: A retrospective analysis

Background

Optimal pain control with limited muscle weakness is paramount for a swift initiation of physical therapy and early discharge. Fascia iliaca compartment block (FICB) has been recommended since it offers good pain control with a low risk of motor block. Pericapsular nerve group (PENG) block with lateral femoral cutaneous block (LFCN) has been proposed as an effective alternative to FICB that offers better pain control with a considerably lower risk of motor block. We aimed to compare the aforementioned blocks and determine which one yielded the lowest numeric rating scale (NRS) score.

Methods

We designed a retrospective analysis of patients undergoing elective total hip arthroplasty. The primary outcome was the NRS score at 6, 12, and 24 hours. The secondary outcomes were total opioid consumption, time to first PRN opioid, and time to first postoperative ambulation.

Results

52 patients were recruited, (13 PENG plus LFCN, 39 FICB). PENG plus LCFN resulted in a lower NRS at all three-time points (mean difference and 95%CI at 6 h 0.378 [-0.483; 1.240], at 12 h 0.336 [-0.378; 1.050], and at 24 h 0.464 [0.013; 0.914] P = 0.02). Moreover, less PRN opioids were requested in the PENG plus LCFN vs. FICB group (0 [0;7.5] vs 60 [15;80] milligrams of morphine equivalents, P = 0.001). No delay in the first ambulation or initiation of physical rehabilitation was reported in either group.

Conclusions

PENG plus LCFN seems to offer better pain control and lead to less PRN opioids. Neither block hindered physical therapy nor ambulation. These results need to be confirmed with a larger prospective and randomized study.

Comparative Evaluation of Analgesic Efficacy of Ultrasound-Guided Pericapsular Nerve Group Block and Femoral Nerve Block During Positioning of Patients With Hip Fractures for Spinal Anesthesia: A Prospective, Double-Blind, Randomized Controlled Study

INTRODUCTION

Hip fractures cause severe pain during positioning for spinal anesthesia (SA). Intravenous systemic analgesics can lead to various complications in elderly patients, hence peripheral nerve blocks are emerging as a standard of care in pain management for hip fractures, among which femoral nerve block (FNB) is widely known and practiced. Pericapsular nerve group (PENG) block is a recently described technique that blocks the articular nerves of the hip with motor-sparing effects and is used to manage positional pain in hip fractures. This study aims to evaluate the analgesic efficacy of PENG block over FNB in managing pain during positioning before SA in hip fractures.

MATERIALS AND METHODS

This was a prospective, randomized, double-blinded study. After ethical clearance, 70 patients undergoing hip fracture surgery under SA in a tertiary-care hospital were recruited and randomized to receive either ultrasound-guided PENG block or FNB with 20 ml of 0.25% bupivacaine before performing SA. We compared pain severity using the visual analog scale (VAS) 15 and 30 minutes after the block and during positioning. The sitting angle, requirement of rescue analgesia for positioning, and anesthesiologist and patient satisfaction scores were also analyzed. Continuous data were analyzed with an unpaired t-test while the chi-square test was used for categorical data.

RESULTS

There was a significant reduction in VAS scores after PENG block (PENG: 0.66 ± 1.05 and FNB: 1.94 ± 1.90; p = 0.001) with lesser requirement of rescue analgesia for positioning compared to FNB. The anesthesiologist and patient satisfaction scores were also significantly better in the PENG group.

CONCLUSION

PENG block offers better analgesia for positioning before SA than FNB without any significant side effects, and improves patient and anesthesiologist satisfaction, thus proving to be an effective analgesic alternative for painful hip fractures.

Efficacy of Supplemental Ultrasound-Guided Pericapsular Nerve Group (PENG) Block Combined with Lateral Femoral Cutaneous Nerve Block in Patients Receiving Local Infiltration Analgesia after Hip Fracture Surgery: A Prospective Randomized Controlled Trial

Background and Objectives: Local infiltration analgesia (LIA) represents a potential approach to reducing pain in patients undergoing total hip arthroplasty (THA). The pericapsular nerve group (PENG) block also provides adequate analgesia for fractures and THA. As most hip surgeries use a lateral incision, affecting the cutaneous supply by branches of the lateral femoral cutaneous nerve (LFCN), the LFCN block can contribute to postoperative analgesia. However, no studies have investigated the effectiveness of supplemental PENG block combined with LFCN block in patients undergoing LIA after hip fracture surgery. Our study aimed to assess the effectiveness of PENG combined with LFCN block following hip fracture surgery in patients who underwent LIA. Materials and Methods: Forty-six patients were randomly assigned to LIA or PENG + LFCN + LIA groups. The primary outcome was the pain score at rest and during movement at 2, 6, 12, 24, and 48 h postoperatively. The total opioid dose for postoperative analgesia was also measured at the same time points. Secondary outcomes included postoperative cognitive function assessment. Results: The median pain scores at rest and during movement were lower in the PENG + LFCN + LIA group throughout the study periods compared to the LIA group, except at 2 h (at rest) and 48 h (during movement) after surgery. The total fentanyl dose was lower in the PENG + LFCN + LIA group at all time points after surgery when compared to the LIA group. Postoperative delirium incidence and the median abbreviated mental test scores were not significantly different between the two groups. Conclusions: The combination of PENG and LFCN blocks may contribute to enhanced recovery for patients undergoing LIA after hip fracture surgery. However, further well-controlled research is necessary to determine the effectiveness of supplemental PENG combined with LFCN block in addressing cognitive deficits in these patients.

Implementation of a Fascia Iliaca Compartment Block Program in Geriatric Hip Fractures: The Experience at a Level I Academic Trauma Center

OBJECTIVES

Determine adherence to a newly implemented protocol of fascia iliaca compartment block (FICB) in geriatric hip fractures.

METHODS

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Patients with a hip fracture treated with cephalomedullary nailing or hemiarthroplasty (CPT codes 27245 or 27236).

OUTCOME MEASURES AND COMPARISONS

Adherence to a protocol for FICB, time intervals between emergency department arrival, FICB, and surgery stratified by time of admission.

RESULTS

Three hundred eighty patients were studied (average age 78 years, 70% female). Approximately 53.2% of patients received an FICB, which was less than a predefined acceptable adherence rate of 75% ( P < 0.001). Approximately 5.0% received an FICB within 4 hours and 17.3% within 6 hours from admission. Admission during daylight hours (7 am -7p m ) when compared with evening hours (7 pm -7 am ) was associated with improved timeliness ([8.3% vs. 0% within 4 hours, P < 0.001] [27.5% vs. 2.4% within 6 hours, P < 0.001]). Improved adherence to the protocol was observed over time (odds ratio: 1.0013, 95% confidence interval, 1.0001-1.0025, P = 0.0388).

CONCLUSIONS

FICB implementation was poor but gradually improved over time. Few patients received an FICB promptly, especially during night hours. Overall, this study demonstrates that implementation of an FICB program at a Level I academic trauma center can be difficult; however, many hurdles can be overcome with institutional support and dedication of resources such as staff, space, and additional training.

Retrospective Analysis of Ultrasound-Guided Serial-Injection Triple Nerve Block Efficacy in Cementless Bipolar Hemiarthroplasty for Femoral Neck Fracture

BACKGROUND

Femoral neck fractures are effectively treated with bipolar hemiarthroplasty (BHA) surgery, yet postoperative pain management remains a challenge. This study explores the efficacy of multimodal pain management in minimizing opioid use and enhancing recovery.

METHODS

A retrospective analysis of 87 patients who underwent BHA between September 2016 and September 2020 was conducted. Patients were analyzed in two groups: Group I (n = 42), receiving serial-injection nerve blocks (SINBs) before and after surgery, and Group II (n = 41), with no SINB. Notably, all nerve blocks for Group I were performed after November 2017, following the implementation of this technique in our protocol. Pain and analgesic medication usage were assessed over 72 h post-surgery, along with hospitalization duration and perioperative complications.

RESULTS

Group I patients exhibited significantly lower pain scores at 6, 12, 24, and 48 h post-surgery, alongside reduced incidences of postoperative nausea and vomiting (PONV) and delirium compared with Group II (p < 0.05).

CONCLUSIONS

Utilizing sequential lower limb nerve blocks under ultrasound guidance in BHA surgeries effectively reduces early postoperative pain and associated adverse effects. This approach demonstrates potential benefits in pain management, leading to diminished narcotic usage and lower risks of PONV and delirium.

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

Aim

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

Methods

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

Results

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

Conclusion

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

Analgesic efficacy of Pericapsular Nerve Group (PENG) block compared with Fascia Iliaca Block (FIB) in the elderly patient with fracture of the proximal femur in the emergency room. A randomised controlled trial

INTRODUCTION AND OBJECTIVES

Data on the efficacy of PENG (Pericapsular Nerve Group) block in hip trauma pain are scarce. We hypothesized that PENG block was more effective than infra-inguinal ultrasound-guided FIB (Fascia Iliaca block) for pain control in patients aged 65 years or older presenting in the emergency room (ER) with traumatic proximal femoral fracture.

MATERIALS AND METHODS

We conducted an exploratory, double-blind, randomized controlled trial. One anaesthesiologist performed the block and another assessed outcomes. Patients were randomly allocated to the PENG group (20 ml ropivacaine 0.375%) or the infrainguinal FIB group (40 ml ropivacaine 0.2%). Standard hypothesis tests (t test or χ2 test) were performed to analyse baseline characteristics and outcome parameters. The primary end-point of the study was analgesic success, defined as "NRS pain score ≤ 4" 30 min after blockade, with PENG vs to FIB. Secondary outcomes were pain at rest ("pain at rest NRS score ≤ 4" 30 min after blockade), duration of analgesia (time to first request for analgesia), need for rescue medication in case of block failure, and complications during blockade.

RESULTS

After obtaining ethical committee approval and written informed consent, 60 patients were included. The primary endpoint was achieved in 16 out of 30 patients (53.3%) in the PENG group and in 15 out of 28 patients (53.6%) in the FIB group. Comparison between groups did not show superiority of the PENG vs FIB (P-value .98).

CONCLUSIONS

PENG block does not provide better pain than FIB in proximal femoral fracture in elderly patients treated in the ER.

Comparison of analgesic effects of pericapsular nerve group block and fascia iliaca compartment block during hip arthroplasty: A systematic review and meta-analysis of randomised controlled trials

Background and Aims

Postoperative pain for patients having hip arthroplasty ranges from moderate to severe. Many regional anaesthesia procedures treat postoperative pain to improve functional ability and quality of life. Evidence comparing the analgesic effects of the pericapsular nerve group (PENG) block and fascia iliaca compartment block (FICB) remains unclear. The analgesic efficacies of PENG and FICB in hip arthroplasty were compared to determine which technique is associated with superior analgesia.

Methods

The electronic databases (PubMed, Cochrane Library, Google Scholar and Web of Sciences) were searched for published randomised controlled trials (RCTs) till 5 April 2023 comparing PENG block vs. FICB following hip arthroplasty. The primary outcome was pain scores [numerical rating scale (NRS) or visual analogue scale (VAS)] between 0 and 10 at rest and during movement at 24 h. Secondary outcomes included pain scores at rest and during movement within 30 min, at 6 h and 12 h, time to first rescue analgesia and cumulative postoperative opioid use in 24 h. We assessed the risk of bias using the Cochrane Collaboration Risk-of-Bias 2 tool. Using Grading of Recommendations Assessment, Development, and Evaluation (GRADE), the certainty of the evidence was assessed. Subgroup analysis was performed to explore the source of heterogeneity.

Results

We included 12 RCTs examining 644 patients. Pain scores at rest at 24 h (standardised mean differences (SMDs): 0.17; 95% confidence interval (CI): -0.90 to 1.23; P = 0.76, moderate certainty) and during movement at 24 h (SMD: -0.58, 95% CI: -1.53 to 0.38, P = 0.24, moderate certainty) were not different in both PENG block and FICB. Pain scores at rest and during movement within 30 min may be lower with PENG block than FICB. However, the pain score at rest and during movement at 6 h and the time to first rescue analgesia were not different between the two treatment arms. The mean opioid consumption in oral morphine equivalents (mg) in 24 h may be lower with PENG than FICB.

Conclusion

We observed no difference between the PENG block and the FICB at 24 h for pain at rest and movement with a moderate degree of certainty. However, PENG block showed improved analgesia within 30 min at rest and during movement, and reduce postoperative opioid consumption in 24 h with moderate certainty of evidence. Further large-scale and high-quality RCTs are required to supplement the present findings.

Emergency Department Pain Management in the Older Adult

Pain assessment and management in older adults is complex and requires evaluation and consideration of the type of pain, the acuity of the condition, comorbidities, and medications. Many older adults do not receive appropriate therapy for painful conditions in the emergency department (ED). This brief review article is focused on pharmacologic agents, drug-drug interactions, drug-disease interactions, and approaches in the management of painful conditions seen in older adults in the emergency department. Recommendations for specific painful conditions such as fragility fractures are discussed.

Regional anesthesia for geriatric population

Advancements in modern health care over 20 years have substantially increased the average lifespan in developed countries, and the fastest growing population is the elderly population. The proportion of people in Saudi Arabia aged 60 or more is predicted to be 25 percent of the total population of 40 million by the end of 2050. Moreover, the number of people aged 80 or more is expected to reach 1.6 million or 4 percent of the total population in the same period. Improvements in surgical techniques, anesthesia, and intensive care units make surgical interventions in older and sicker patients possible. It is estimated that over half of the population older than 65 years will require surgical intervention at least once during the remainder of their lives. Therefore, elderly patients are becoming an even larger part of anesthetic practice. Regional anesthesia (RA) is frequently used in elderly patients, especially during orthopedic surgery, genitourologic and gynecologic procedures, and hernia repair. Although age can no longer be considered a contraindication to anesthesia and surgery, anesthesia-related morbidity and mortality remain higher among elderly than among young adult surgical patients. Undoubtedly, peripheral nerve (PN) blocks improve analgesia and reduce opioid consumption and their associated side effects. This is beneficial in the perioperative care of elderly patients who may have less physiologic reserve to withstand the side effects of general anesthesia (GA).

Applying the Suprainguinal Approach of Fascia Iliaca Compartment Block for Surgical Anesthesia in a Patient Undergoing Emergency Femoral Thrombectomy: A Case Report

We present the first documented case of achieving surgical anesthesia for a vascular surgery using the suprainguinal approach of the fascia iliaca compartment block (SFICB), in a patient with severe comorbidities from the cardiovascular system. More specifically, a male elderly patient with a history of cardiac amyloidosis, severe aortic stenosis, and coronary artery disease, was in need of emergent thrombectomy due to acute lower limb ischemia. During the evaluation of this patient, general and neuraxial anesthesia were both considered. However, the former would expose him to the risk of myocardial ischemia and other complications due to cardiovascular instability caused by the general anesthetic agents while the latter was absolutely contraindicated due to recent clopidogrel use and the specific pathophysiology changes induced by cardiac amyloidosis. Thus, a peripheral nerve block was deemed to be the best option in this case. SFICB, despite being challenging, could offer adequate analgesic results so it was the anesthetic technique of choice. The surgery was completed and the patient recovered appropriately. The aim of this report is to discuss the specific anesthetic considerations of this case, highlight the ability of SFICB to achieve surgical anesthesia in vascular surgeries, and increase familiarity with the procedure.

[Use of regional anesthesia for preoperative analgesia for proximal femoral fractures in the emergency department : A survey on current practice in German-speaking countries and the United Kingdom]

BACKGROUND

Regional anesthesia (RA) techniques such as femoral nerve block (FNB) or fascia iliaca compartment block (FICB) are effective analgesia techniques in the treatment of pain from proximal femoral fractures (PFF). While in Great Britain (GB) these are already frequently used in the emergency department for preoperative analgesia, in the German-speaking D‑A-CH area (Germany, Austria, Switzerland) this seems to occur much less frequently. Therefore, the aim of this study was to survey the type and frequency of RA procedures used and to compare international practice.

MATERIAL AND METHODS

In the D‑A-CH area as well as in GB, registered emergency departments were contacted and invited to participate in an online survey. The survey included questions on the frequency and type of RA procedures, reasons for non-use, equipment used, person performing the procedure and medications used.

RESULTS

The participation rate was 17.4% (142/818 emergency departments). RA procedures for preoperative analgesia in PFF were used in 18.3% (21/115) of hospitals in the D‑A-CH region and in 96.3% (26/27) in GB. The most commonly used block was the FICB in GB at 96.2% (25/26) and the FNB in Germany at 66.7% (14/21). In the D‑A-CH area, RA procedures are primarily performed by anesthesiology specialists 71.4% (15/21), and in GB by emergency department residents 65.4% (17/26).

DISCUSSION

RA procedures are still performed too rarely following PFF in emergency departments in the D‑A-CH area. In international comparison with GB there is potential for improvement.

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.

A comparison of different volumes of bupivacaine used in fascia iliaca compartment block

BACKGROUND

Fascia iliaca compartment block (FICB) is one of the regional techniques applied for post-operative pain control after femoral and knee surgery. To the best of our knowledge, there are limited reports focusing on local anesthetic (LA) volume. Our aim in this study was to find the most clinically effective volume by comparing three different volumes of LA used frequently in the literature for US-guided infra-inguinal FICB for post-operative pain control in patients undergoing femur and knee surgery.

METHODS

A total of 45 patients with ASA I-III physical scores were included in the study. When the surgical procedure was completed under general anesthesia, FIKB was applied with 0.25% Bupivacaine under ultrasound guidance to the patients before extu-bation. Patients were randomly divided into three different groups for the volume of local anesthetic to be administered. Bupivacaine was administered 0.3 mL/kg in Group 1, 0.4 mL/kg in Group 2 and 0.5 mL/kg in Group 3. After FIKB, the patients were extubated. The patients were followed up for 24 h postoperatively in terms of vital signs, pain scores, additional analgesic requirement, and possible side effects.

RESULTS

When the post-operative pain scores were compared, the scores of Group 1 were found to be statistically higher than Group 3 at the post-operative 1st, 4th, and 6th h (p<0.05). When the additional analgesia requirement compared, the post-operative 4th h was highest in Group 1 compared to the other groups (p=0.03). At the post-operative 6th h, additional analgesic requirement was less in Group 3 than in the other groups, and there was no difference between Groups 1 and 2 (p=0.026). As the LA volume increased, the amount of analgesic consumed in the first 24 h decreased, but there was no statistically significant difference (p=0.051).

CONCLUSION

Our study showed that ultrasound-guided FIKB is a safe and effective method for post-operative pain relief as a part of multimodal analgesic components, and 0.25% bupivacaine in 0.5 mL/kg volume provides more effective analgesia than the other two groups without any side effects.

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 fascia iliaca block versus quadratus lumborum block for perioperative analgesia in patients undergoing hip surgery. A randomised controlled trial

INTRODUCTION

Femoral neck fractures are common orthopaedic fractures, especially in old age, and they represent a life-threatening condition requiring surgical intervention. In this study, we aimed to compare 2 regional techniques used to decrease perioperative pain.

MATERIAL AND METHODS

In this parallel group randomized controlled clinical trial we enrolled 68 patients from both sexes scheduled for hip surgery after femoral neck fractures. The patients were randomly allocated to 2 equal groups with one receiving ultrasound- guided supra-inguinal fascia iliaca block (FIB) and the other receiving ultrasound- guided anterior quadratus lumborum block (QLB). Our primary outcome was the duration of postoperative analgesia. The secondary outcome was measuring the Visual Analog Scale (VAS) during patient positioning while applying the neuraxial block, the total analgesic requirement in the postoperative period, patient satisfaction in the postoperative period, and the frequency of adverse effects.

RESULTS

The group receiving supra-inguinal FIB had a significantly longer time of postoperative analgesia 18 (4-24), compared to the group receiving anterior QLB 2 (1-24), P = 0.005. They consumed less morphine throughout 24 hours postoperatively, 5.3 ± 0.9 mg compared to 6.9 ± 1.87 mg (95% CI: 6.45-3.92, P = 0.008), and they showed less pain during positioning for spinal anaesthesia.

CONCLUSIONS

Supra-inguinal FIB provides prolonged postoperative analgesia compared to anterior QLB in patients undergoing hip surgery. It was associated with less pain during positioning in spinal anaesthesia and decreased total morphine consumption.

Prehospital Ultrasound-Guided Pediatric Fascia Iliaca Block

The fascia iliaca block (FIB) provides effective regional anesthesia for fractures of the femur. There is 1 previous case report of a prehospital FIB in a child using a landmark technique. We report the successful prehospital application of a FIB using ultrasound guidance in a 7-year-old girl.

ASSESSMENT OF THE EFFICIENCY OF ANALGETIC ACTION OF ULTRASOUND-GUIDED FICB AS A COMPONENT OF PERIOPERATIVE MULTIMODAL ANALGESIA IN ERAS- STRUCTURE IN OBESE PATIENTS UNDERGOING TOTAL HIP REPLACEMENT

OBJECTIVE

The aim: To compare the efficiency of analgetic action of Ultrasound-guided FICB and prolonged EA as the components of perioperative multimodal analgesia in ERAS-structure in obese patients undergoing THR.

PATIENTS AND METHODS

Materials and methods: The retrospective study included 80 patients with obesity, who underwent elective anterolateral THR under conditions of low-flow inhalation anesthesia with sevoflurane in combination with PEA (n1=38) or with FICB (n2=42). Primary endpoints: VAS pain level during the first postoperative day.

RESULTS

Results: Static and dynamic VAS pain scores were similar in both groups during the first 6 hours. Since the 8th postoperative hour, there was a statistically significant increase in both static and dynamic VAS pain scores in the FICB group. A significant difference in static and dynamic VAS pain scores was obtained with a trend toward an increase in the PEA group within 48 hours (p < 0.05).

CONCLUSION

Conclusions: USG- FICB is an effective, practically feasible, minimally invasive and safe regional method for eleclive anterior-lateral THR and can be an alternative to PEA in obese patients.

Interventional therapies for management of hip fracture pain peri-operatively: A review article

Background

Hip fracture is a common reason for elderly admission to hospital and majority of patients will require a hip fixation surgery. Pain originating from a hip fracture is usually severe and the need to improve comfort is paramount, especially before the hip fixation surgery because severe pain results in unnecessary stress response such as catecholamines release, tachycardia and hypertension. This worsens outcomes, increases risk of complications such as myocardial ischaemia, strokes, pulmonary embolus or deep vein thrombosis. Multimodal systemic analgesia has been shown to be effective in reducing pain in hip fractures but the associated side effects and contraindications have accelerated the adoption of nerve blocks in the peri-operative management of hip fracture patients. 1 As a result, this has been increasingly recognised as a important component of the hip fracture pathway (as part of a multimodal approach for analgesia) and many hospitals have protocols to perform various interventional therapies (various nerve blocks) for newly admitted patients with hip fracture to alleviate pain immediately and potentially provide intra and post-operative analgesia.

Objective

The aim of this review is to elucidate the various interventional therapies currently available (including pericapsular nerve group (PENG) block which was first described in 2018), their evidence and the pros and cons.

Methods

We reviewed the latest evidence for femoral nerve block (FNB), 3-in-1 block, lumbar plexus block (LPB), fascia iliaca block (FIB), erector spinae plane block (ESPB) and pericapsular nerve group (PENG) block.

Results and conclusion

Each block has its pros and cons, as discussed in this review article. The procedurist should deliberate these considerations before deciding which block is most appropriate.

PERIPHERAL NERVE BLOCKS FOR HIP FRACTURES IN EMERGENCY MEDICINE

Hip fractures represent a major public health issue with increasing incidence as a population ages. The aim of this review is to describe peripheral nerve block techniques (the fascia iliaca compartment block and the pericapsular nerve group block) as pain management for hip fractures in emergency medicine, and to emphasize their benefits. Hip fractures are extremely painful injuries. The pain itself is unpleasant for patients and if left untreated it can lead to multiple complications during preoperative, operative and postoperative patient management. Pain management for elderly hip fracture patients is often challenging. Non-steroidal anti-inflammatory drugs are not recommended due to their side effects, the increased risk of gastrointestinal bleeding, renal function impairment and platelet aggregation inhibition. Paracetamol alone is often insufficient, and opioids have many potentially harmful side effects, such as delirium development. Peripheral nerve blocks for hip fractures are safe and effective, also in emergency medicine settings. The benefits for patients are greater pain relief, especially during movement, less opioid requirements and decreased incidence of delirium. Regional analgesia should be routinely used in hip fracture pain management.

Effectiveness of pericapsular nerve group block with ultrasonography in patients diagnosed with hip fracture in the emergency department

BACKGROUND

Hip fractures (HF) are among the most common fractures present in the emergency department and are very painful. Pericapsular nerve group block (PENG) is a new regional anesthesia technique developed for analgesia in total hip arthroplas-ties. We aimed to determine the effectiveness of PENG block used to reduce pain in patients with HF in the emergency department.

METHODS

This single-center, randomized, and prospective study was carried out in the emergency department. The patients in-cluded in the study were selected according to the suitability of the personnel who will perform the procedure. The sealed envelope system was used for randomization.

RESULTS

Statistical analysis was performed with 39 patients (18 patients in the PENG group, 21 patients in the control group). Thir-teen (33.3%) of the patients were female and 26 (66.7%) were male. The mean age was 75.3. At rest post-procedure, the mean Numeric Rating Scale (NRS) scores of the patients at the 30th min, 2nd, 6th, and 24th h were 1.78±1.83, 0.00±0.00, 0.00±0.00, and 1.28±1.41 in the PENG group. On the other hand, it was 3.38±1.86, 0.05±0.22, 2.86±2.37, and 4.95±1.47 in the control group, respectively. The mean NRS scores of the patients at 15° elevation of the leg at the 30th min, 2nd, 6th, and 24th h were 3.06±1.80, 0.06±0.24, 0.22±0.43, and 2.44±1.50 in the PENG group and it was 5.24±1.81, 1.05±0.92, 4.29±2.35, and 7.14±1.24 in the control group, respectively.

CONCLUSION

PENG block can reduce pain and the need for systemic analgesics as a practical option in patients with HF.

Fascia Iliaca Blocks Performed in the Emergency Department Decrease Opioid Consumption and Length of Stay in Patients with Hip Fracture

OBJECTIVES

To examine the impact of fascia iliaca (FI) blocks performed in the emergency department on patients with hip fracture on opioid consumption, length of stay, and readmission rate.

DESIGN

Prospective cohort study.

SETTING

Community-based Level 1 trauma center.

PATIENTS/PARTICIPANTS

Ninety-eight patients with isolated femoral neck, intertrochanteric, and subtrochanteric femur fractures (OTA/AO 31-A and 31-B) presenting from January 1, 2020, to June 30, 2020.

INTERVENTION

Ultrasound-guided FI compartment block using 40 mL of 0.25% bupivacaine.

MAIN OUTCOME MEASUREMENTS

Opioid consumption, length of stay, discharge disposition, and 30-day readmission rate.

RESULTS

Thirty-three patients had contraindication to FI block. Thirty-nine of 65 patients (60%) without contraindications to undergoing FIB received FI block. Mean age, body mass index, fracture type, and surgical procedure were similar between patients undergoing FIB and not receiving FIB. The FIB group had significantly lower opioid consumption preoperatively [17.4 vs. 32.0 morphine milliequivalents (MMEs)], postoperatively (37.1 vs. 85.5 MMEs), over total hospital stay (54.5 vs. 117.5 MMEs), and mean opioid consumption per day of hospital stay (13.3 vs. 24.0 MMEs). Patients in the FIB group had shorter length of stay compared with the control group (4.3 vs. 5.2 days). There was no significant difference in discharge disposition destination between groups. No patients reported complications of FI block.

CONCLUSIONS

Undergoing FI block in the emergency department was associated with decreased opioid consumption, decreased length of stay, and decreased hospital readmission within 30 days of hip fracture.

LEVEL OF EVIDENCE

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

Comparison of USG-guided or landmark approach fascia iliaca compartment block for positioning in elderly hip fracture patients with spinal anesthesia: a randomized controlled observational study

Background/aim

Currently, the elderly population in the world is rapidly increasing due to technological developments and convenient access to health services. Due to comorbidities in elderly patients, hip fractures are frequently observed after exposure to environmental trauma. To reduce pain during positioning in spinal anesthesia, fascia iliaca compartment block (FICB) can be applied easily and reliably. In our study, we aimed to compare the analgesic effects and duration of fascia iliaca compartment blocks performed with USG guidance or the landmark approach methods for relieving spinal anesthesia position pain.

Materials and methods

Our study included 100 patients undergoing operations due to hip fracture and administered spinal anesthesia after FICB. The group with USG-guided FICB (USG) had the blockage needle advanced to the compartment under the fascia iliaca, and 15 mL bupivacaine + 10 mL 2% lidocaine was administered. They were placed in sitting position for spinal anesthesia 20 min later and procedure duration and numerical rating scale (NRS) scores were recorded. In the group with landmark approach FICB (LAND), the spina iliaca anterior superior (SIAS) and pubic tubercle were connected with a line. The same amount of local anesthetic was administered to the external 1/3 portion of this line with the double pop technique. Procedure duration and NRS scores were recorded.

Results

There was no statistically significant difference between the two groups in terms of NRS scores (p: 0.073). There was a statistically significant difference in duration of FICB administration between the two groups (p < 0.001).

Conclusion

Both USG-guided and landmark approach FICB methods provide adequate and similar analgesia for positioning in spinal anesthesia. However, in cases where there is no problem with access to the ultrasound device or time, safer blockage can be provided by imaging neurovascular structures with ultrasound.

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.

Effectiveness of Fascia Iliaca Compartment Block after Elective Total Hip Replacement: A Prospective, Randomized, Controlled Study

Objective: An assessment of the feasibility of fascia iliaca compartment block (FICB) combined with nonopioid analgesics and patient controlled analgesia (PCA), oxycodone, in the perioperative anaesthetic management for elective total hip replacement (THR). Design: A randomised, single-center, open-label study. Setting: A single hospital. The study was conducted from October 2018 to May 2019. Participants: In total, 109 patients were scheduled for elective total hip replacement. Interventions: Postoperative FICB with 0.375% ropivacaine in conjunction with nonopioid analgesics (paracetamol, metamizole, and pregabalin) and oxycodone as rescue analgesia. Measurements: Pain intensity was measured using the Numeric Pain Rating Scale (NRS) at rest and during rehabilitation, the total dose of postoperative oxycodone required, the occurrence of opioid-related adverse events, patient hospitalisation time, and level of satisfaction. Follow-up period: 48 h. Main Results: A total of 109 patients were randomised into two groups and, of these, 9 were subsequently excluded from the analysis (three conversions to general anaesthesia, two failures to perform FICB, four failures to use the PCA pump). Patients in the FICB group received standard intravenous analgesia with FICB, and those in the control group were managed with standard intravenous analgesia only. Pain level measured with NRS was significantly lower at rest and during rehabilitation in the FICB group. Oxycodone use in the first 48 h was significantly higher in the control group (p < 0.001); additionally, the time to the first dose of rescue analgesia was significantly shorter (p < 0.001). In the control group, there was a higher rate of side effects and a significantly longer hospitalisation time (p < 0.001). Similarly, higher satisfaction with the applied analgesic treatment was noted in the FICB group. Conclusions: FICB in elective THR treatments is an effective form of analgesia, which reduces the need for opioids, the number of complications, the length of hospitalisation, and which ensures a high level of patient satisfaction with the analgesic treatment used. Trial registration: ClinicalTrials.gov No. NCT04690647.

Pragmatic comparative effectiveness study of multimodal fascia iliaca nerve block and continuous lumbar epidural-based protocols for periacetabular osteotomy

Perioperative pain management protocols have a significant impact on early surgical outcomes and recovery. We hypothesized that multimodal protocol including fascia iliaca compartment nerve block (MM-FICNB) would decrease the length of hospital stay (LOS) by facilitating earlier mobilization, without compromising analgesia, compared to a traditional lumbar epidural-based protocol (EP). Demographics/comorbidities, surgical/block characteristics and perioperative pain/mobilization data were collected from a prospectively recruited MM-FICNB group (N = 16) and a retrospective EP cohort (N = 16) who underwent PAO using similar surgical techniques, physical therapy/discharge criteria. Association of MM-FICNB group with LOS (primary outcome), postoperative pain, postoperative opioid requirements in morphine equivalent rates (MER) (mcg/kg/h) and time to complete physical therapy were tested using multivariable and survival regression. Patient and surgical characteristics were similar between groups. Median time for FICNB performance was significantly less than epidural (6 versus 15 min; P < 0.001). LOS was significantly decreased in the MM-FICNB group (2.88 ± 0.72 days) compared to the EP group (4.38 ± 1.02 days); P < 0.001. MM-FICNB group had significantly lower MER on POD1 (P = 0.006) and POD2 (P < 0.001), with similar pain scores on all POD. MM-FICNB group was associated with decreased LOS and earlier mobilization (P < 0.001) by covariate-adjusted multivariate regression. Cox proportional hazard regression model showed MM-FICNB subjects had 63 (95% CI 7–571, P < 0.001) times the chance of completing physical therapy goals, compared to EP. Compared to EP, MM-FICNB protocol allowed earlier mobilization and decreased post-surgical hospitalization by 1.5 days, without compromising analgesia, with important implications for value-based healthcare and cost-effectiveness.

Ultrasound-guided Fascia Iliaca Plane Block for the treatment of donor site pain in the burn injured patient: a randomized control trial

Burn injuries requiring surgical intervention often result in split- thickness skin grafting procedures, with donor skin frequently harvested from the patient's anterolateral thigh. The donor site is often reported as the primary site of post-operative pain due to the damage sustained to localised nociceptors.A randomised control trial was undertaken to evaluate the impact an ultrasound-guided regional nerve block would have on patient reported pain scores in donor site wounds, and associated rescue analgesia consumption. Twenty participants requiring split-skin grafting for burn injuries of <15% total body surface area were enrolled from a tertiary burns unit and randomised to control (10 participants) or intervention group (10 participants). The intervention group received the addition of an ultrasound-guided facia iliaca plane block prior to their surgery. Primary outcome was pain score in the donor site during the postoperative phase; while secondary outcome was pain on day 1 post-surgery as measured by the numeric pain score (0-10). During the post-operative phase, the intervention group had a significantly lower median donor site pain score of 0 (interquartile range (IQR) 0 - 0), compared to the control group median 6 (IQR 4 - 7) (p < 0.001). Day 1 post-surgery the intervention group had a median pain score of 0 (IQR 0 - 4) compared to control group median 4.5 (IQR 2 - 6) (p= 0.043).The study findings demonstrated that regional anaesthesia was an effective way to reduce pain scores and requirement for additional analgesics during the postoperative phase.