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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 31  |  Issue : 3  |  Page : 175-179

Evaluation of two different dosages of local anesthetic solution used for ultrasound-guided femoral nerve block for pain relief and positioning for central neuraxial block in patients of fracture neck of the femur


Department of Anesthesiology and Critical Care, INHS Asvini, Mumbai, Maharashtra, India

Date of Web Publication18-Jan-2018

Correspondence Address:
Vidhu Bhatnagar
Department of Anesthesiology and Critical Care, INHS Asvini, Near RC Church, Colaba, Mumbai - 400 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_57_17

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  Abstract 


Introduction: Surgical management of the fracture femur is preferred so as to prevent complications associated with prolonged immobilization. Central neuraxial blockade (CNB) is an attractive option for these patients, and an optimal positioning of the patient is a definite requirement. Owing to the pain associated with movement of the fractured limb, it becomes difficult for the patients to give suitable positioning. Femoral nerve block (FNB) features as a rescue analgesia so as to provide adequate analgesia for facilitation of satisfactory positioning. Aim: This study aims to compare analgesic effect of two different dosages of local anesthetic (LA) solution administered for ultrasonography (USG)-guided FNB given to facilitate optimal positioning for conduct of CNB. Materials and Methods: After taking permission from the institutional review board, eighty patients were enrolled in the study to find out the efficacy of dosage of LA solution for FNB in providing pain relief caused by movement of fractured limb during conduct of regional anesthesia. Informed consent was taken. All patients were given USG-guided FNB. Patients were randomized using a computer-generated random number table, into two groups of forty patients each. Group A patients received USG-guided 12 ml of LA solution containing 10 ml lignocaine solution without preservative (2%) plus 2 ml normal saline (NS), while Group B patients received USG-guided 15 ml of LA solution containing 13 ml lignocaine solution without preservative (2%) plus 2 ml NS for positioning before combined spinal epidural. Results: A total of eighty patients, divided randomly into two groups, were enrolled in the study. Demographics (age, sex, weight, and American Society of Anesthesiologists grades) were similar in both groups. No statistical significance was found in the numeric rating scale scores at baseline, zero minutes, 5, and 15 min in both the groups. Conclusion: USG-guided FNB with 12 ml of LA solution was as effective as 15 ml of LA solution for achieving adequate pain relief so as to give optimal positioning for CNB in patients of fracture neck of femur.


How to cite this article:
Karmarkar AA, Bhatnagar V, Dwivedi D, Das A. Evaluation of two different dosages of local anesthetic solution used for ultrasound-guided femoral nerve block for pain relief and positioning for central neuraxial block in patients of fracture neck of the femur. Indian J Pain 2017;31:175-9

How to cite this URL:
Karmarkar AA, Bhatnagar V, Dwivedi D, Das A. Evaluation of two different dosages of local anesthetic solution used for ultrasound-guided femoral nerve block for pain relief and positioning for central neuraxial block in patients of fracture neck of the femur. Indian J Pain [serial online] 2017 [cited 2019 Oct 16];31:175-9. Available from: http://www.indianjpain.org/text.asp?2017/31/3/175/223669




  Introduction Top


In geriatric patients, fracture femur posttrivial trauma is a common finding. Injury to periosteum is very painful; therefore, fracture femur patients experience excruciating pain during mobility and positioning of the lower limb. Surgical repair is the treatment of choice to make patients ambulant early and prevent complications such as deep venous thrombosis due to immobility. Surgical repair comprises of either replacement of femoral head or internal fixation of the fracture. Both general anesthesia (GA) as well as central neuraxial blockade (CNB) can be utilized as technique of anesthesia for these surgeries. CNB is the preferred technique for surgeries for fracture femur.[1],[2]

The advantage of CNB is that an adequate pain relief is provided to the patients extending even up to the postoperative period. The disadvantage is that satisfactory analgesia is required for positioning for the conduct of CNB because any movement in the injured limb leads to agonizing pain. Therefore, adequate analgesia is required for optimal positioning of the patient for CNB. Modalities of analgesia utilized for positioning during CNB are opioids, nonsteroidal anti-inflammatory drugs if not contraindicated, regional blocks such as fascia iliaca block as well as femoral nerve blocks (FNB).[3],[4]

Conventionally, FNB was given blindly by anatomic landmarks;[5] however, after the advent of ultrasonography (USG), the localization of femoral nerve became much easier.[6] The amount of local anesthetic (LA) to be injected for FNB could also be reduced. We conducted a prospective, observational, randomized study to ascertain the optimal dosage of LA solution required for USG-guided FNB for positioning during combined spinal-epidural (CSE) block.


  Materials and Methods Top


This is a prospective, observational, randomized, blinded study. After taking permission from the institutional review board, eighty patients with fracture neck of the femur listed for internal fixation or hip replacement were enrolled in this study. They were randomized using a computer-generated random number table, into two groups of forty patients each. Group A patients received USG-guided 12 ml of LA solution containing 10 ml lignocaine solution without preservative (2%) plus 2 ml normal saline (NS) for positioning before CSE. Group B patients received 15 ml of LA solution containing 13 ml lignocaine solution without preservative (2%) plus 2 ml NS for positioning before CSE. An evening before surgery, numeric rating scale (NRS) was explained to the patient, and informed consent was taken after explaining the procedure for FNB before positioning.

Patients of either sex, 50–90 years of age, or American Society of Anesthesiologists (ASA) physical grading I–III were included in the study. Exclusion criteria included patient refusal to participate in the study, presence of any coagulation disorders, presence of multiple fractures, any patients with head injury or other injuries, patients with allergy to LA solution, and patients with history of loss of consciousness or in sepsis, skin lesions, or infection at the site of FNB injection.

All patients were preloaded with crystalloids 10 ml/kg in the preoperative area. After shifting in the preoperative induction room, severity of pain was assessed with the help of NRS which was taken as reading baseline. Zero on NRS denotes no pain whereas ten on NRS denotes the maximum pain. The standard monitoring was ensued: heart rate (HR), noninvasive blood pressure, electrocardiography, and pulse oximetry (SpO2). Under USG (SonoSite, MicroMaxx) guidance using linear array probe (8–13 Hz), after delineation of anatomy of the femoral nerve, a short 22-gauge 50-mm needle (Stimuplex needle) with an inline approach was inserted and LA solution was injected.

Pain was assessed by NRS in both the groups at baseline, zero minutes, and then every 5 min after administration of the FNB, till 15 min. Baseline reading of NRS was taken when the patient entered the induction room for the FNB procedure and the monitors for monitoring were attached. Zero minutes reading was noted when the FNB was instituted.

If NRS was <4 after 15 min, the patient was positioned for CSE (sitting/lateral position). If NRS was >5 after 15 min, technique of anesthesia was changed to GA and the patient was excluded from the study. Final analgesic score was noted when the patient was given sitting position for conduct of CSE block. Hemodynamics (mean arterial pressure [MAP] and HR) were noted at baseline, zero minutes, and at every 5 min after the administration of the FNB till CSE was given (25 min). Baseline reading of MAP and HR was taken when the monitors for monitoring were attached to the patient after his/her entry to the induction room for the FNB procedure. When the FNB was instituted, 0 min reading was noted.

Patient comfort was assessed after CSE was established and final supine position was given to the patient. Patients were asked to grade their comfort as: “Yes, comfortable while positioning” or “No, not comfortable while positioning.” Thus, patients were evaluated for degree of pain relief using NRS score and patient comfort while positioning.

The primary objective of our study was to compare analgesic effect of two different dosages of LA solution administered for USG-guided FNB. The secondary objectives were to compare patient comforts in both the groups and any hemodynamic changes. Complications, postadministration of FNB, were also noted. The data collector, who took NRS scores as well as the participating patient, was blinded to the amount of drug injected for the FNB.

Statistical analysis was conducted using unpaired “t”-test for continuous variables. Parametric variables were described as mean ± standard deviation (SD), whereas qualitative variables were described as numbers in percentage. Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA, version 17.0) software was utilized for analysis. P < 0.05 was considered statistically significant.

Iamaroon et al., in their study on evaluation of analgesia for positioning patients with fractured femur using FNB versus fentanyl in 2010, found FNB to be more effective form of analgesia.[7] The mean score was two in FNB group. Keeping alpha error as 0.05 and beta error as 0.20 and considering a significant difference at mean difference of 2.2 in pain score, with SD of 3.0, a sample size of 32/group was required for one-tailed testing. We enrolled 80 patients (40 in each group) catering for dropouts, refusal to participate, and any technical difficulties.


  Results Top


Eighty patients were enrolled in this study and divided randomly into two groups (Group A: n = 40; Group B: n = 40) [Figure 1]. Demographic analysis of age, sex, weight, and ASA grades was found well matched in both the groups [Table 1].
Figure 1: Consort diagram

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Table 1: Demographic data

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NRS scores at baseline, zero minutes, 5, 10, and 15 min were analyzed and no statistical significance was found in both the groups [Table 2].
Table 2: Numeric Rating Scale assessment between the groups

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Secondary outcomes, MAP and HR, were comparable in both the groups at baseline, zero minutes, 5, 10, 15, 20, and 25 min [Figure 2] and [Figure 3].
Figure 2: Comparison of means of mean arterial pressure between the two groups

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Figure 3: Comparison of means of heart rate between the two groups

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Ninety percent patients in Group A were comfortable during positioning for CSE as compared to 92% patients being comfortable during positioning in Group B [Figure 4].
Figure 4: Assessment of patient comfort between the two groupsalso

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  Discussion Top


The number of elderly patients who present with fracture femur has increased over the years, and they have multiple comorbidities. Thus, the requirement of anesthesia for surgical repairs has increased. Urwin et al. and Sorenson and Pace both reported in their articles that the risk of deep vein thrombosis was greater for patients receiving GA as compared to those receiving regional anesthesia (RA).[8],[9] RA was associated with decreased mortality at 1 month which was shown by a Cochrane Review, although the statistical significance was only borderline.[10] Moreover, the time to ambulation was also less in the patients of RA.[10] At our institute, RA is the preferred choice for surgical repair of fracture femur, more so CSE. The immediate problem faced is the excruciating pain when trying to position the patient for conduct of CSE. There are various methods utilized for alleviating pain so as to aid positioning in the patients for CSE. Agents such as midazolam, ketamine, and propofol were utilized as shown by Sandby-Thomas et al.[11] Other drugs such as fentanyl, morphine, and paracetamol infusion have been also utilized for the same purpose. It was demonstrated by Schiferer et al. and Fletcher et al. that adequate analgesia was provided by FNB for patient transport after femoral trauma.[12],[13] FNB is an effective method for alleviating pain in patients with fractured femur, thus helping in manipulation and transportation, which was demonstrated by a study conducted by Berry.[14] Gosavi et al. in 2001, Jadon et al. in 2002, and Sia et al. in 2004 compared opiates with FNB for analgesia for fracture neck of the femur and found adequate, and a faster onset pain relief was noted in the FNB group.[15],[16] Sia et al. used 1.5% lignocaine on 20 patients and established that the time to perform spinal anesthesia (SA) was shorter in the FNB group. They also found that quality of patient positioning for SA was higher in the FNB group.[16]

Walker et al. conducted a Cochrane Database study in 2009 and determined that USG-guided peripheral nerve blocks given by experienced anesthesiologist provided as good success rates as any other method for peripheral nerve location. They also concluded that USG-guided blocks improve the onset time and quality of the block as well as reduce complication rates.[17]

FNB with lignocaine provides adequate analgesia in fracture femur cases which was established by earlier studies, and the success rates with USG-guided blocks were comparable to any other methods; thus, we selected two different dosages of lignocaine: group A was 12 ml (10 ml lignocaine without preservative 2% plus 2 ml of NS) and Group B was 15 ml (10 ml lignocaine without preservative 2% plus 2 ml of NS), as the drug for the USG-guided FNB.

We waited for 15 min for checking the final NRS for positioning because the time of onset of action of lignocaine is 5 min and duration of action is 60–80 min. Since anesthetic technique using a combination of FNB plus CSE is time-consuming, we gave the FNB in preoperative induction room with complete monitoring so as to minimize the “in between patient” time. Since we required pain relief for satisfactory positioning of patient for CSE, we used only lignocaine solution and that is why we wanted to find out the efficacy of a lower volume of solution (12 ml containing 10 ml 2% lignocaine plus 2 ml NS). We used NRS for pain assessment in our patients because we found it easier to explain to the patients. The baseline NRS scores were comparable in both the groups: mean (SD) in Group A was 6.05 (0.79) while mean (SD) in Group B was 6.01 (1.23), with a P = 0.829. The NRS at 5 min when compared in between both the groups was also similar: mean (SD) in Group A was 1.90 (0.88) and in Group B was 1.87 (0.79), with a P = 0.872. A similar study by Gosavi et al. using LA solution containing mixture of 10 mL of 2% lidocaine, 1 mL of sodium bicarbonate, and 4 mL of NS was utilized for giving FNB. The onset time for analgesia was found to be 5 ± 0.54 min in his study.[18]

NRS at 15 min from FNB application was also similar in both the groups with no statistical significance [Table 2]. Patient comfort when assessed in both the groups was also similar after institution of CSE, thus indirectly endorsing that the pain relief was adequate and parallel in both the groups. This determines that 12 ml LA solution is as efficacious in pain relief as 15 ml LA solution for USG-guided FNB [Figure 4].

The MAP and HR were also similar at 5, 15, and 25 min, most probably owing to comparable pain relief in both the groups. The results of our study establishing sufficient pain relief by FNB are in comparison to the studies quoted above.[7],[14],[15],[16],[18] There were no complications in our study. Berry in 1977 and Denton and Manning in 1988 also did not report any complications in their studies using FNB.[14],[15],[18],[19]

Filippo et al. in 2013 considered various studies regarding minimum effective anesthetic volume of LA for surgical anesthesia. They deliberated on various studies to demonstrate the efficacy of USG-guided blocks in reducing the amount of LA used for surgical anesthesia vis-à -vis blocks performed blindly or with the help of electrical nerve stimulation.[20] The results of their study were variable and were not able to specify an effective dose for each block in any explicit manner, but they concluded that the use of USG aided in decreasing the dose of LA for peripheral nerve blocks.[20]

We found that 12 ml LA solution was as effective as 15 ml LA solution for providing adequate pain relief to fracture femur cases for optimal positioning for CNB, but the limitations in our study are that blinding of the anesthesiologists giving the FNB could not be performed; however, the data collector was blinded to both the groups. Although the demographic was similar, the appropriate matching could not be performed because of the presence of heterogeneous sample population. The pain threshold varies with individuals; thus, there could be a bias while actual assessment of pain postprocedure. We could not comment on the minimum effective volume of LA solutions for blockade of femoral nerve because the earlier studies have used 15–20 ml of LA solutions for FNB, and our institutional review board did not allow us to use LA solutions <12 ml for the procedure.

Future research should include time from trauma to surgery in the study design, and patients should be randomized and stratified equally in each treatment group.


  Conclusion Top


We could determine by conducting this study that a 12 ml LA solution containing 10 ml 2% lignocaine plus 2 ml NS, when compared with a 15 ml LA solution containing 13 ml 2% lignocaine plus 2 ml NS, provided satisfactory pain relief for positioning during CSE in patients of fracture femur.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sutcliffe AJ. Anaesthesia for fractured neck of femur. Anaesth Intensive Care 2006;7:75-7.  Back to cited text no. 1
    
2.
Stanley I. The anaesthetic management of upper femoral fracture. Curr Anaesth Crit Care 2005;16:23-33.  Back to cited text no. 2
    
3.
Mosaffa F, Esmaelijah A, Khoshnevis H. Analgesia before performing a spinal block in the lateral decubitus position in patients with femoral neck fracture: A comparison between fascia iliaca block and IV fentanyl (Abstract). Reg Anesth Pain Med 2005;30:61.  Back to cited text no. 3
    
4.
Sia S, Pelusio F, Barbagli R, Rivituso C. Analgesia before performing a spinal block in the sitting position in patients with femoral shaft fracture: A comparison between femoral nerve block and intravenous fentanyl. Anesth Analg 2004;99:1221-4.  Back to cited text no. 4
    
5.
Khoo ST, Brown TC. Femoral nerve block – The anatomical basis for a single injection technique. Anaesth Intensive Care 1983;11:40-2.  Back to cited text no. 5
    
6.
Marhofer P, Schrögendorfer K, Koinig H, Kapral S, Weinstabl C, Mayer N, et al. Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anesth Analg 1997;85:854-7.  Back to cited text no. 6
    
7.
Iamaroon A, Raksakietisak M, Halilamien P, Hongsawad J, Boonsararuxsapong K. Femoral nerve block versus fentanyl: Analgesia for positioning patients with fractured femur. Local Reg Anesth 2010;3:21-6.  Back to cited text no. 7
    
8.
Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: A meta-analysis of randomized trials. Br J Anaesth 2000;84:450-5.  Back to cited text no. 8
    
9.
Sorenson RM, Pace NL. Anesthetic techniques during surgical repair of femoral neck fractures. A meta-analysis. Anesthesiology 1992;77:1095-104.  Back to cited text no. 9
    
10.
Parker MJ, Handoll HH, Griffiths R. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev 2004;4:CD000521.  Back to cited text no. 10
    
11.
Sandby-Thomas M, Sullivan G, Hall JE. A national survey into the peri-operative anaesthetic management of patients presenting for surgical correction of a fractured neck of femur. Anaesthesia 2008;63:250-8.  Back to cited text no. 11
    
12.
Schiferer A, Gore C, Gorove L, Lang T, Steinlechner B, Zimpfer M, et al. A randomized controlled trial of femoral nerve blockade administered preclinically for pain relief in femoral trauma. Anesth Analg 2007;105:1852-4, table of contents.  Back to cited text no. 12
    
13.
Fletcher AK, Rigby AS, Heyes FL. Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: A randomized, controlled trial. Ann Emerg Med 2003;41:227-33.  Back to cited text no. 13
    
14.
Berry FR. Analgesia in patients with fractured shaft of femur. Anaesthesia 1977;32:576-7.  Back to cited text no. 14
    
15.
Jadon A, Kedia SK, Dixit S, Chakraborty S. Comparative evaluation of femoral nerve block and intravenous fentanyl for positioning during spinal anaesthesia in surgery of femur fracture. Indian J Anaesth 2014;58:705-8.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Sia S, Pelusio F, Barbagli R, Rivituso C. Analgesia before performing a spinal block in the sitting position in patients with femoral shaft fracture: A comparison between femoral nerve block and intravenous fentanyl. Anesth Analg 2004;99:1221-4.  Back to cited text no. 16
    
17.
Walker KJ, McGrattan K, Aas-Eng K, Smith AF. Ultrasound guidance for peripheral nerve blockade. Cochrane Database Syst Rev 2009;4:CD006459.  Back to cited text no. 17
    
18.
Gosavi CP, Chaudhari LS, Poddar R. Use of femoral nerve block to help positioning during conduct of regional anesthesia. Bombay Hosp J 2001;43:531-2.  Back to cited text no. 18
    
19.
Denton JS, Manning MP. Femoral nerve block for femoral shaft fractures in children: Brief report. J Bone Joint Surg Br 1988;70:84.  Back to cited text no. 19
    
20.
Filippo AD, Falsini S, Adembri C. Minimum anesthetic volume in regional anesthesia by using ultrasound-guidance Brazilian. English Edition. J Anesthesiol 2016;66:499-50.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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