Fascia iliaca block in the emergency department for hip fracture: a randomized, controlled, double-blind trial

Comparison of traditional systemic analgesic, single shot or continuous fascia iliaca compartment block for pain management in patients with hip or proximal femoral fractures: A protocol for systematic review and network meta-analysis

INTRODUCTION

Pain management for hip and proximal femoral fractures includes oral and parenteral opioids and various regional anesthesia techniques. Fascia iliaca compartment blocks (FICB) are commonly used for these patients. At present, a unified view of the analgesic effect of FICB has not been reached. In addition, the comparison between single shot FICB and continuous FICB has not elicited clear evidence-based results. We will compare the efficacy and safety of systemic analgesics, single shot or continuous FICB in the pain management, complication prevention and satisfaction, in our systematic review and network meta-analysis.

METHODS

China National Knowledge Infrastructure, Chinese Biomedical Literatures database, PubMed, the Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, EMBASE, and Web of Science will be searched until June 2023. Two authors will independently screen the studies for eligibility and perform data extraction. The Cochrane risk of bias tool (RoB 2) will be used to assess the quality of evidence. We will use the GRADE approach to assess the certainty of the evidence across studies included in this review. All the statistical analyses will be conducted using Rev Man 5.3, WinBUGS 1.4.3, and Stata 13.

ETHICS AND DISSEMINATION

Our review involves a secondary analysis of existing published studies, therefore there is no need for formal research ethics approval. We will disseminate our findings through publication in a peer-reviewed journal.

PROTOCOL REGISTRATION

PROSPERO, CRD42023425282.

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.

The addition of peripheral nerve blocks to routine spinal or general anesthesia was associated with decreased risks of major adverse events after total hip or knee arthroplasty: A retrospective, propensity score-matched cohort study

Background

Although total joint arthroplasty is the most effective procedures for end-stage arthritis, the incidence of postoperative death and complications remains high. The association of additional peripheral nerve blocks (PNBs) to routine spinal or general anesthesia with major adverse events (including mortality and complication rates) in elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) has been subject to inconclusive findings.

Methods

This retrospective observational single institution study included all patients ≧ 18 years undergoing their first elective THA or TKA from January 1, 2012 to December 31, 2021. A 1:2 propensity score matching (PSM) was performed to account for the baseline differences between two groups that were accepted to PNB or not. Kaplan-Meier curves were employed to estimate the effects of PNB on mortality. The associations of PNB and the complications were assessed by logistic regression models.

Results

We identified 1328 patients, among whom 197 had PNB and 1131 had not. The 90-day all-cause mortality was significantly reduced in patients with PNBs (0 % vs 2.79 %, P = 0.041) after THA or TKA, when compared to the non-PNB group. PNB was also associated with a lower risk of pulmonary complications (odds ratio [OR], 0.430; 95%confidence interval [CI],0.216-0.857) and deep vein thrombosis (OR, 0.103; 95%CI, 0.011-0.954).

Interpretation

The results of this observational, propensity score-matched cohort study suggested a strong association between the addition of PNBs to routine spinal or general anesthesia and decreased risks of major adverse events.

Peripheral Nerve Blocks in the Preoperative Management of Hip Fractures: A Systematic Review and Network Meta-Analysis

STUDY OBJECTIVE

We conducted a systematic review and network meta-analysis to evaluate the comparative efficacy of peripheral nerve block types for preoperative pain management of hip fractures.

METHODS

We searched Cochrane, Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar for randomized clinical trials. We included participants aged more than 16 years with hip fractures who received peripheral nerve blocks or analgesics for preoperative pain management. The primary outcomes were defined as absolute pain score 2 hours after block placement, preoperative consumption of morphine equivalents, and length of hospital stay. We used a random-effects network meta-analysis conceptualized in the Bayesian framework. Confidence of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA).

RESULTS

We included 63 randomized controlled studies (4,778 participants), of which only a few had a low risk of bias. The femoral nerve block, 3-in-1 block, fascia iliaca compartment block, and pericapsular nerve group block yielded significantly lowered pain scores at 2 hours after block placement compared with those with no block (standardized mean differences [SMD]: -1.1; 95% credible interval [CrI]: -1.7 to -0.48, [confidence of evidence: low]; SMD: -1.8; 95% CrI: -3.0 to -0.55, [low]; SMD: -1.4; 95% CrI: -2.0 to -0.72, [low]; SMD: -2.3; 95% CrI: -3.2 to -1.4, [moderate], respectively). The pericapsular nerve group block, 3-in-1 block, fascia iliaca compartment block, and femoral nerve block resulted in lower pain scores than the no-block group. Additionally, the pericapsular nerve group block yielded a lower pain score than femoral nerve block or fascia iliaca compartment block (SMD: -1.21; 95% CrI: -2.18 to -0.23, [very low]: SMD: -0.92; 95% CrI: -1.70 to -0.16, [low]). However, both the fascia iliaca compartment block and femoral nerve block did not show a reduction in morphine consumption compared with no block. To our knowledge, no studies have compared the pericapsular nerve group block with other methods regarding morphine consumption. Furthermore, no significant difference was observed between peripheral nerve blocks and no block in terms of the length of hospital stay.

CONCLUSIONS

Compared with no block, preoperative peripheral nerve blocks for hip fractures appear to reduce pain 2 hours after block placement. Comparing different blocks, pericapsular nerve group block might be superior to fascia iliaca compartment block and femoral nerve block for pain relief, though the confidence evidence was low in most comparisons because of the moderate to high risk of bias in many of the included studies and the high heterogeneity of treatment strategies across studies. Therefore, further high-quality research is needed.

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.

Implementing a Fascia Iliaca Compartment Block Curriculum in an Emergency Medicine Residency Program

With pain being commonly stated as a reason for presentation to the emergency department (ED) and the advent of the opioid crisis in the United States, regional anesthesia has been gaining prominence as an alternative treatment for acute pain in emergency medicine. However, to this date, there is no widely agreed-upon and standardized training regimen for regional anesthesia in emergency medicine residency programs. In this paper, we set out to define elements of competency for a residency program in a large academic tertiary center and to create a protocol for resident training that could be easily replicated, with a secondary goal of increasing the frequency of nerve blocks in the ED. We also aimed to discuss a curriculum that has been shown to improve resident comfortability with the fascia iliaca compartment block (FICB). This led to a substantial increase in nerve blocks performed in the ED. However, we also demonstrate a loss of retention at six months, indicating that further curriculum refinements will be needed to promote longitudinal retention of knowledge.

From the Operating Room to the Cave: Ultrasound-Guided Locoregional Anesthesia in the Setting of Cave Rescue-A Description of 2 Cases

Caving accidents are rare, but when they occur, they represent a unique logistical and medical challenge. Retrieving the patient to the surface often means navigating stretchers through narrow corridors with limited options for monitoring and interventions. Because the patient is usually not fasting, opioids and sedatives should be used with extreme caution. Therefore, alternative analgesic techniques such as locoregional nerve blocks are a promising strategy to improve patient comfort and safety during cave rescues. In this article, we describe 2 cases in which portable point-of-care ultrasound equipment was used to supplement clinical assessment and provide locoregional anesthesia to facilitate patient evacuation and transport. In this context, we discuss the role of portable ultrasound-guided locoregional anesthesia in cave rescue and in the global preclinical context. In summary, our cases demonstrated that the administration of ultrasound-guided prehospital locoregional anesthesia is a safe, rapid, and effective procedure even in extreme situations such as cave rescues. The advent of portable, high-quality ultrasound equipment may open the door for more widespread application of this technique in the global preclinical setting.

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.

Regional anesthesia in the emergency department outside the operating theatre

PURPOSE OF REVIEW

Moderate to severe pain is common and remains a significant problem in the emergency department and regional anesthesia provides optimal and safe pain relief. This review aims to discuss the benefits, indications of the most common ultrasound-guided regional anesthesia techniques that can be provided by clinicians in the emergency department as part of multimodal analgesia. We will also comment on the education and training for effective and safe ultrasound-guided regional anesthesia in the emergency department.

RECENT FINDINGS

The emergence of multiple new fascial plane blocks that provide easier to learn alternatives, yet effective analgesia for specific patient groups can now safely be taught and utilized in the emergency department.

SUMMARY

Emergency physicians are perfectly placed to utilize the advantages of ultrasound-guided regional anesthesia. Various techniques can now be employed to cover most of the painful injuries presenting to the emergency department, thus modifying the morbidity and outcomes of emergency patients. Some of the new techniques require minimal training, provide safe and effective pain relief with low risk of complications. Ultrasound-guided regional anesthetic techniques should form an integral part of the curriculum of emergency department physicians.

Fascia Iliaca Block in Hip and Femur Fractures to Reduce Opioid Use

BACKGROUND

Fascia iliaca compartment block (FICB) has become a keystone technique for acute pain management in patients with hip and proximal femur fractures.

OBJECTIVES

To demonstrate that administering FICB preoperatively to patients with hip or proximal femur fractures in the emergency department (ED) is likely to reduce opioid use and related complications, and to decrease hospital length of stay (LOS).

METHODS

An unblinded study of adult patients with hip and proximal femur fractures who consented to receive an FICB with 30 cc of bupivacaine with epinephrine administered in the ED. We compared this group with a contemporaneous group of controls who only received systemic opioids. Over the course of approximately 6 months, main outcome measured between the two groups was amount of morphine equivalents given from block administration until 8 h after. We also compared complications such as delirium, constipation, and bleeding rates (oozing from injection site or hematoma formation).

RESULTS

A total of 166 patients with hip and proximal femur fractures from August 12, 2018 to April 25, 2021; 81 received FICB plus systemic opioids, and 85 received only systemic opioids. Among the FICB group, morphine equivalents were reduced by 0.6 mg/h with no significant difference in LOS. A statistically significant difference in opioid-related adverse outcomes was found between the anticoagulated group vs. the no anticoagulation group.

CONCLUSIONS

FICB is a safe and effective preoperative technique for initial pain management in patients with hip and proximal femur fractures, as it can also be used with additional systemic opioids. FICB administration may reduce systemic opioid use preoperatively, thus reducing opioid-related adverse effects with no significant impact on hospital LOS.

Fascia iliaca block for hip fractures in the emergency department: meta-analysis with trial sequential analysis

BACKGROUND

Fascia iliaca block (FICB) has been used to reduce pain and its impact on geriatric patients with hip fractures.

OBJECTIVE

We conducted this meta-analysis to investigate the analgesic efficacy of this block in comparison to standard of care (SOC) when performed by non-anesthesiologist in the emergency department.

METHODS

Search on PubMed, SCOPUS, EMBASE, Google Scholar and Cochrane database for randomized and quasi-randomized trials were performed. The primary outcome was to compare pain relief at rest at 2-4 h. The pain relief at various time intervals, reduction in opioid use, the incidence of nausea/ vomiting, delirium and length of hospital stay were the secondary outcomes studied. Trial Sequential Analysis (TSA) was performed for the primary outcome.

RESULTS

Eleven trials comprising 895 patients were included in the meta-analysis. Patients receiving FICB had significant better pain relief at rest at 2-4 h with mean difference of 1.59 (95% CI, 0.59-2.59, p = 0.002) with I² = 96%. However, the certainty of the evidence was low and TSA showed that the sample size could not reach the requisite information size. A significant difference in pain relief at rest and on movement started within 30 min and lasted till 4 h of the block. Use of FICB was associated with a significant reduction in post-procedure parenteral opioid consumption, nausea and vomiting and length of hospital stay.

CONCLUSIONS

FICB is associated with significant pain relief both at rest and on movement lasting up to 4 h as well as a reduction in opioid requirement and associated nausea and vomiting in geriatric patients with hip fracture. However, the quality of evidence is low and additional trials are necessary.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Fascia Iliaca Compartment Block for Hip Fractures: Improving Clinical Practice by Audit

Background

Hip fractures are the most frequently occurring serious injury in older people. They are the most common reason for people over the age of 65 to need emergency anaesthesia and surgery, and account for the most cause of death following an accident. A fascia iliaca compartment block (FICB) is the injection of anaesthetic agents into the fascia iliaca compartment with the effect of blocking the lumbar plexus via an anterior approach. FICB targets nerves that are in the fascia iliaca compartment that include the femoral nerve and the lateral femoral cutaneous nerve. A FICB is clinically safe and efficient providing consistent analgesic effects irrespective of the performing doctor's experience in managing hip fractures. Clinical audits and feedback are a veritable tool for quality improvement.

Methods

Data from the National Hip Fracture Database (NHFD) for all patients admitted with a hip fracture between October 2018 and May 2019 at a District hospital was interrogated and audited. Results of this audit were discussed in the department's and the Trust's mortality review meetings. In addition, teaching sessions on the safe administration of FICB using the Loss of Resistance (LOR) technique were held for junior doctors. A re-audit was carried out in May 2020 where a retrospective study of patients admitted with a hip fracture over six months from October 2019 to April 2020 was done to assess improvement in compliance rates in the administration of fascia iliaca blocks.

Results

This study showed a statistically significant increase in the number of patients who got a fascia iliaca block on presentation with a fractured neck of the femur from after our second audit (p < 0.00001). There were no complications associated with the administration of FICB to patients with hip fractures.

Conclusions

The administration of FICB for patients with hip fractures by admitting junior doctors using the loss of resistance (LOR) technique is a safe, simple, and rapidly effective pain management method that reduces the need for excessive systemic analgesia and provides consistent simultaneous blockade of the lateral cutaneous femoral and femoral nerves. This study showed that clinical practices could be improved through audits, staff education and by enforcing the proper utilization of clinical proformas to ensure compliance.

Can emergency nurses safely and effectively insert fascia iliaca blocks in patients with a fractured neck of femur? A prospective cohort study in an Australian emergency department

AIMS AND OBJECTIVES

To compare the effectiveness and safety of ultrasound-guided fascia iliaca block (FIB) insertion in patients with fractured neck of femur by trained emergency nurses with insertion by doctors.

BACKGROUND

The FIB is an effective and safe form of analgesia for patients with hip fracture presenting to the emergency department (ED). While it has traditionally been inserted by medical doctors, no evidence exists comparing the effectiveness and safety of FIB insertion by nurses compared with doctors.

DESIGN

A prospective cohort study.

METHODS

The study was conducted in an Australian metropolitan ED. Patients admitted to the ED with suspected or confirmed fractured neck of femur had a FIB inserted under ultrasound guidance by either a trained emergency nurse or doctor. A retrospective medical record audit was undertaken of consecutive ED patients presenting between January 2013-December 2017. Reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cohort studies.

RESULTS

Of the 472 patients eligible for a FIB, 322 (68%) had one inserted. A majority were inserted by doctors (n = 207, 64.3%) with 22.4% (n = 72) by nurses and in 13.3% (n = 43) of patients the clinician was not documented. There were no differences between the nurse-inserted and doctor-inserted groups for mean pain scores 1 hr post-FIB insertion; clinically significant reduction (≥30%) in pain score 1 hr post-FIB insertion; pain score 4 hr post-FIB insertion; delirium incidence; opioid use post-FIB insertion; or time to FIB insertion. No adverse events were identified in either group.

CONCLUSION

Insertion of FIBs by trained emergency nurses is as effective and safe as insertion by doctors in patients with fractured neck of femur in the ED. Senior emergency nurses should routinely be inserting FIB as a form of analgesia for patients with hip fracture.

RELEVANCE TO CLINICAL PRACTICE

Our study showed trained emergency nurses can safely and effectively insert fascia iliaca blocks in patients with hip fractures. Pain was significantly reduced in a majority of patients with no reported complications. Emergency nurses should be trained to insert fascia iliaca blocks in patients with hip fractures.

The Application of Fascia Iliaca Compartment Block for Acute Pain Control of Hip Fracture and Surgery

PURPOSE OF REVIEW

Over 300,000 patients are hospitalized annually following hip fractures in the USA. Many patients experienced inadequate analgesia. We will review the perioperative effects of the fascia iliaca compartment block (FICB) in hip fracture patients.

RECENT FINDINGS

FICB by injecting local anesthetics beneath the fascia iliaca results in significant pain relief in hip fractures. Neuropathies and vascular injuries are almost unlikely. Single-shot FICB is faster to place, yet providing about 8 h of analgesia when bupivacaine is used. Continuous FICB provides prolonged titratable analgesia, improved patient satisfaction, and leads to faster hospital discharge. FICB reduces opioid consumption, decreases morbidity and mortality, reduces hospital stay, reduces delirium, and improves satisfaction. FICB should form part of a multimodal analgesic regime, in the context of a multidisciplinary approach to the management of hip fracture patients. More clinical investigations are needed to validate the long-term outcome benefits of FICB in hip fracture patients.

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.

Fascia Iliaca Compartment Block for Perioperative Pain Management of Geriatric Patients with Hip Fractures: A Systematic Review of Randomized Controlled Trials

Background

With continuous increase of the aging population, the number of geriatric patients with fragility hip fractures is rising sharply, and timely surgery remains the mainstay of treatment. However, adequate and effective pain control is the precondition of satisfactory efficacy. This systematic review aimed to summarize the use of fascia iliaca compartment block (FICB) as an analgesic strategy for perioperative pain management in geriatric patients with hip fractures.

Methods

PubMed and Embase databases were searched for English published randomized controlled trials (RCTs) reporting application of FICB for pain control of the older adults with hip fractures between January 1^st, 2000, and May 31^st, 2020. The modified Jadad scale was used to evaluate quality of the RCTs included. Primary outcomes of the eligible RCTs were presented and discussed.

Results

A total of 27 RCTs with 2478 cases were included finally. The present outcomes suggested, after admission or in the emergency department (ED), FICB can provide patients with equal or even better pain relief compared with the conventional analgesia methods, which can also reduce additional analgesic consumptions. While, before positioning for spinal anesthesia (SA), FICB is able to offer superior pain control, facilitating SA performance, after surgery FICB can effectively alleviate pain with decreased use of additional analgesics, promoting earlier mobilization and preventing complications.

Conclusions

FICB is a safe, reliable, and easy-to-conduct technique, which is able to provide adequate pain relief during perioperative management of geriatric patients with hip fractures.

<p>Educational e-Learning Tool to Improve Fascia Iliac Block Uptake for Neck of Femur Fracture Patients: A Multi-Disciplinary Approach</p>

Background

There are 75,000 neck of femur (NOF) fractures that occur each year in England and Wales. Prompt, adequate analgesia is a major priority in hip fracture management to reduce the risk of delirium and facilitate earlier return to mobility and independence. NICE guidelines recommend the use of fascia iliaca block (FIB) for NOF fracture patients. Current literature suggests that FIB significantly improves pre-operative pain scores; however despite this, the uptake of FIB still varies between centers.

Objective

The study aimed to review pre-operative analgesia management of NOF patients in our center. The primary endpoint was to improve uptake of regional fascia iliaca block (FIB) in NOF patients by means of an educational e-learning tool.

Study Design and Methods

We performed a prospective review of all patients with NOF fractures admitted via the emergency department from September to October 2018 in a single district general hospital in the UK. We recorded patient demographics, time of admission, grade of physician performing block and pain scores and total FIB uptake. A multidisciplinary-led, short interventional training program of FIB administration was then developed and delivered to all relevant staff. Pain management and pain scores were recorded in a second prospective cycle along with uptake of FIB.

Results

There was a 53.2% reduction in pain score in the group that received FIB compared to 26.7% in patients who received oral analgesia only, consistent with current literature (p value = 0.0046). There was a significant increase (2.66x) in FIB administration by orthopedic doctors (27.3% in cycle 1 to 100% in cycle 2) after the educational session intervention.

Conclusion

This study shows that with the use of an educational training tool, all members of the multidisciplinary team can successfully administer FIB without any complications. Our educational tool has enabled a significant increase in delivery of FIB.