Elsevier

Journal of Clinical Anesthesia

Volume 35, December 2016, Pages 398-403
Journal of Clinical Anesthesia

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

https://doi.org/10.1016/j.jclinane.2016.09.014Get rights and content

Highlights

  • We compare the analgesic efficacy of intravenous fentanyl and fascia iliaca block.

  • Fentanyl and fascia iliaca block both provide analgesia while positioning for spinal in patients with femur fractures.

  • Fascia iliaca block provides superior analgesia and positioning.

Fascia iliaca block also provides postoperative comfort.

Abstract

Study objective

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

Setting

Operating room.

Patients and interventions

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

Measurements

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

Main results

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

Conclusion

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

Introduction

Fracture of the femur occurs most commonly after trauma or trivial fall especially in the elderly. This causes significant morbidity. Surgery for fracture femur may be done under regional or general anesthesia. It has been shown that regional anesthesia is associated with lesser morbidity and mortality compared to general anesthesia [1], [2], [3], [4]. A study comparing effectiveness of regional vs general anesthesia for hip surgery reviewed 18,158 patients among whom 5254 (29%) patients received regional anesthesia. Regional anesthesia was associated with a lower adjusted odds of mortality compared to general anesthesia [3]. Thus, femur fracture surgeries are performed safely under regional anesthesia.

Subarachnoid block is administered in either the sitting or lateral position. Positioning patients for spinal anesthesia with fractured femur is challenging because even minimal overriding of the fracture ends is exceedingly painful [5]. Providing analgesia before positioning not only increases patient comfort but also improves positioning and successful spinal block.

Nociception arises from the periosteum, which is very painful [6]. Pain causes spasm of the thigh muscles, which further displaces the fracture ends and worsens the pain cycle.

Blocks of the femoral nerve such as the classical femoral nerve block [6], [7], [8], 3-in-1 block [9], [10], or fascia iliaca block [11], [12], [13] can serve to provide analgesia and as a method to facilitate positioning before spinal anesthesia. Fascia iliaca block is a safe and easy method to position patients before administering spinal anesthesia even in poor-risk patients such as those with renal and respiratory compromise where opioids are to be avoided [14].

Analgesia before positioning is also provided by conventional methods such as intravenous nonsteroidal anti-inflammatory drugs and opioids [5], [6], [7], [11]. In this study, comparative analgesic efficacy of fascia iliaca block vs intravenous fentanyl was assessed with respect to positioning patients before spinal anesthesia.

Section snippets

Materials and methods

After obtaining ethical committee clearance (ethics committee of the MS Ramaiah Medical College and Hospitals, protocol no. STD-1/EC/0451/2011 approved on October 31, 2011) and informed consent from patients, 60 patients undergoing surgery for fracture femur were chosen for the study. Patients included were adults aged between 25 and 75 years, with American Society of Anesthesiologists (ASA) status I to III and all types of femoral neck fractures. All patients were operated on by 1 of 4

Results

There were no significant differences in demographic data (Table 1). All patients in both groups had either intertrochanteric fracture or neck of femur fractures with similar distribution between groups. Types of surgeries performed in both groups were similar in distribution.

In IVF group, 12 of 30 patients received 3 boluses of fentanyl, and 18 of 30 patients received at least 2 boluses of fentanyl before positioning. Repeat boluses of fentanyl were given only if VAS was >50 mm when asked to

Discussion

This study was done to compare the analgesic efficacy of FICB and a conventionally used opioid such as fentanyl for positioning patients with femoral fractures for spinal anesthesia. Femur fractures occur after even a trivial fall in the elderly. Various factors such as altered cognitive function, neuromuscular degeneration, reduced bone mineral density, and environmental factors are responsible for trivial injury causing fractures in the elderly [15].

Irrespective of the etiology of injury,

Conclusion

Fascia iliaca block is a simple and easily learned procedure which can be used in providing comfort to patients with femoral fractures in the preoperative and postoperative settings. We conclude that the fascia iliaca block offers superior analgesia in comparison to IVF in patients with femur fracture before positioning for spinal anesthesia.

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      Citation Excerpt :

      Patients who received FICB reported less pain during placement compared to the patients who received IVF (24.72 ± 15.70 mm versus 61.22 ± 18.18 mm on the VAS; P = 0.01). Moreover, the sitting angle was improved in the FICB group compared to the IVF group (56.17° ± 16.54° versus 21.38° ± 23.90°; P = 0.01) [99]. This finding is similar to a study by Sia et al. in which femoral nerve block provided improved positioning compared to IV fentanyl in patients who underwent surgery for femoral shaft fractures [100].

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    This work is attributed to the Department of Anesthesiology, MS Ramaiah Medical College and Hospitals, Bangalore.

    ☆☆

    Funding: None.

    Conflict of interest/disclosures: None.

    1

    Present address: Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareilly Road, Lucknow 226014, India.

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