Indian Journal of Pain

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 32  |  Issue : 3  |  Page : 150--154

A comparative study of ultrasound-guided femoral nerve block versus fascia iliaca compartment block in patients with fracture femur for reducing pain associated with positioning for subarachnoid block


Neena Jain, Pooja Rawat Mathur, Veena Patodi, Saurav Singh 
 Department of Anaesthesiology, Jawaharlal Nehru Medical College, Ajmer, Rajasthan, India

Correspondence Address:
Dr. Pooja Rawat Mathur
131/1, Jeevan-Jyoti, Shantipura, Ajmer - 305 001, Rajasthan
India

Abstract

Context: Lower extremity peripheral nerve blocks are increasingly being recommended for pain control in patients with fracture femur as it reduces pain and shortens the duration of hospital stay. Aims: To compare analgesic efficacy of ultrasound guided femoral nerve block (FNB) and fascia iliaca compartment block (FICB) in patients with fracture femur for reducing pain associated with positioning for subarachnoid block. Settings and Design: It was a prospective, randomized, double blind study. Methods and Material: Group A (n = 25) received ultrasound guided FNB and Group B (n = 25) received ultrasound guided FICB using 0.5% ropivacaine. Primary objective was to observe reduction in pain associated with positioning (sitting) for subarachnoid block. Statistical Analysis used: For data analysis t test, Mann Whitney test and Chi-square test were applied. Results: Visual analog scale (VAS) score for pain before giving peripheral nerve block between Group A (7.60 ± 0.57) and Group B (7.44 ± 0.50) was comparable (P = 0.302). VAS score for pain in sitting position before giving subarachnoid block was lesser in Group A (1.88 ± 0.83) than in Group B (2.40 ± 0.57) (P = 0.013). Mean reduction in VAS score for pain was more in Group A (5.72 ± 0.73) compared to Group B (5.04 ± 0.73) (P = 0.002). Conclusion: Ultrasound guided FNB is more efficacious in reducing pain associated with positioning (sitting) for subarachnoid block in patients undergoing surgery for fracture femur compared to ultrasound guided FICB.



How to cite this article:
Jain N, Mathur PR, Patodi V, Singh S. A comparative study of ultrasound-guided femoral nerve block versus fascia iliaca compartment block in patients with fracture femur for reducing pain associated with positioning for subarachnoid block.Indian J Pain 2018;32:150-154


How to cite this URL:
Jain N, Mathur PR, Patodi V, Singh S. A comparative study of ultrasound-guided femoral nerve block versus fascia iliaca compartment block in patients with fracture femur for reducing pain associated with positioning for subarachnoid block. Indian J Pain [serial online] 2018 [cited 2019 Mar 26 ];32:150-154
Available from: http://www.indianjpain.org/text.asp?2018/32/3/150/249098


Full Text

 Introduction



Femur fracture is a very painful condition perioperatively, which is further exaggerated by movements.[1],[2] Paracetamol, nonsteroidal anti-inflammatory drugs, and opioids have their limitations, ranging from mild systemic side effects such as nausea, vomiting, constipation, and urinary retention to serious complications such as respiratory depression and nephrotoxicity and are often contraindicated due to their interactions with other drugs.[3],[4]

Regional analgesia overcomes the shortcomings and offers an attractive alternative to systemic analgesics for perioperative use.[2],[3],[4],[5],[6] Lower extremity peripheral nerve blocks are increasingly being recommended for pain control in patients with fracture femur as it reduces pain, time to first rescue analgesia, need for systemic analgesics, and incidence of delirium and shortens the duration of hospital stay.[5],[6],[7],[8]

The femoral nerve block (FNB) and fascia iliaca compartment block (FICB) are simple methods which require minimal instruments with few absolute contraindications, being hypersensitivity to local anesthetic agents or the presence of vascular or neurological problems in the affected limb.[1] However, these simple techniques are underused in the management of pain relief in femur fracture.

Ultrasound guidance improves visualization of anatomical structures, success rate, quality of sensory block, and onset time and decreases dose of local anesthetics and complications compared to nerve stimulator or landmark techniques.[9]

Studies have compared FNB with FICB, employing the use of nerve stimulator and landmark technique, but the use of ultrasound-guided (USG) technique to compare these two blocks remains unexplored.

In the present study, we compared the analgesic efficacy of USG FNB with USG FICB using 0.5% ropivacaine in patients with fracture femur in reducing pain associated with positioning (sitting) for subarachnoid block.

Duration of analgesia, perioperative patient comfort, and complications were also assessed.

 Subjects and Methods



A prospective study was initiated after clearance from the institutional ethical committee. Based on the study by Ghimire et al., the sample size was calculated to be 22 patients in each group, keeping a power of 0.8 and α error of 0.05. To allow for study error and attrition, final sample size of 25 patients were randomly allocated to each group.[10]

After valid written and informed consent, a total of 50 adult patients (18–80 years) with American Society of Anesthesiologists (ASA) Physical Status 1 and 2 posted for elective surgery for fracture femur were allocated into two groups using a computer-generated table of random numbers.

Patients with psychiatric illness, anxious or agitated patients, presence of peripheral sensorineural deficit, allergic to local anesthetic agents, on anticoagulants, infection at the site of block performance, sepsis, vertebral column deformity, suspected compartment syndrome in the lower limbs, on analgesics within 8 h before performing nerve block were excluded from the study. The anesthetist performing the block was not blinded to the procedure, but the patient and assessor of pain visual analog scale (VAS) score were blinded to group allocation.

Preparations for giving general anesthesia, emergency resuscitation, and ultrasound equipment for the peripheral nerve block were kept ready. On arrival of the patient in the operation theater, pain VAS score was assessed using a standard 10-cm VAS, with 0 corresponding to no pain and 10 designating the worst possible pain.

The site to be blocked was painted with 5% povidone–iodine followed by spirit and was draped. A linear 7–13 MHz ultrasonography probe (SonoScape A8, SonoScape Medical Corp., Shenzhen, China) was used with in-plane approach of needle (18G Tuohy needle) advancement. Probe was moved laterally or medially and rocked back and forth until a good-quality picture was obtained. Mark on the probe was always kept on the lateral side for image orientation. Optimal gain, depth, and focal point were set to obtain the best possible view of the concerned anatomical structures.

Group A (n = 25) received USG FNB. Landmark included the identification of femoral nerve lateral to femoral artery at the level of femoral crease followed by injection of 0.5% ropivacaine 20 ml after careful aspiration adjacent to femoral nerve.[11],[12],[13]

Group B (n = 25) received USG FICB. Landmarks included identification of femoral artery, iliopsoas muscle, fascia iliaca, and sartorius muscle followed by injection of 0.5% ropivacaine 30 ml after careful aspiration between fascia iliaca and iliopsoas muscle.[11],[12],[13],[14]

Twenty minutes after the peripheral nerve block, patients were placed in sitting position for subarachnoid block and pain VAS score was assessed. Injection bupivacaine 0.5% heavy 15 mg was given intrathecally using a 25G Quincke needle.

Duration of analgesia was defined as loss of pinprick sensation in the anterior part of thigh (after the peripheral nerve block) to either when pain VAS score was >3 (assessed every hour postoperatively) or when the patient demanded for rescue analgesia. Perioperative patient comfort was assessed postoperatively using the standard 10-cm VAS for comfort, with 0 corresponding to least comfortable and 10 designating the most comfortable state.[15] Complications such as nausea, vomiting, hypotension, bradycardia, hematoma, and local anesthetic toxicity were carefully monitored.

No loss of pinprick sensation in the anterior part of thigh within 20 min of performing the peripheral nerve block was considered as block failure. Such patients were excluded from the study.

Variables were analyzed statistically and expressed as mean ± standard deviation. Categorical data were compared using Chi-square test. Quantitative parametric data were analyzed using unpaired Student's t-test while nonparametric data were analyzed using Mann–Whitney test. P < 0.05 was considered statistically significant. GraphPad Prism software version 6.01 for Windows (GraphPad Software Inc., La Jolla, California, USA, 2012) was used for data tabulation and analysis.

 Results



Both groups were comparable in terms of demographic profile such as age, sex, weight, ASA physical status, distribution of fracture, and types of surgery performed as evident from [Table 1]. VAS score for pain before performing peripheral nerve block between Group A (7.60 ± 0.57) and Group B (7.44 ± 0.50) was comparable (P = 0.30) [Table 2]. VAS score for pain in the sitting position before giving subarachnoid block was significantly less in Group A (1.88 ± 0.83) when compared to Group B (2.40 ± 0.57) (P = 0.01) [Table 2].{Table 1}{Table 2}

Mean reduction in VAS score for pain was also more in Group A (5.72 ± 0.73) compared to Group B (5.04 ± 0.73) (P = 0.00) [Figure 1]. Duration of analgesia between Group A (480.3 ± 39.85 min) and Group B (458.8 ± 42.68 min) was comparable (P = 0.07) [Figure 2]. VAS score for perioperative patient comfort between Group A (7.52 ± 0.50) and Group B (7.44 ± 0.50) was comparable (P = 0.58) [Figure 3]. No complications were observed in both groups.{Figure 1}{Figure 2}{Figure 3}

 Discussion



Anesthetic technique most commonly used for patients with fracture femur includes neuraxial blocks, with subarachnoid block being routinely used.[10],[16]

Positioning of the patients with femur fracture is a painful condition as evident from pain VAS scores assessed before performing the peripheral nerve block in our study as well as previous studies.[1],[4],[5] Moreover, patients presenting with fracture femur usually are the elderly and have multiple comorbidities, which precludes the use of systemic analgesics.

Sandby-Thomas et al. in their survey on perioperative management of patients with fracture femur reported that the most frequently used agent for analgesia and sedation during patient positioning for subarachnoid block was midazolam followed by ketamine and propofol. Other alternative agents were rarely used, and these included nitrous oxide, sevoflurane, and remifentanil. Nerve blocks were used infrequently to aid with positioning. No sedation or analgesia was given for positioning in 15.1% of patients.[16] A 2012 survey of three Toronto, Ontario–area hospitals found that regional nerve blocks for hip fractures were performed by only 33% of attending emergency physicians and only 6% performed them often or almost always.[17] A 2009 survey in the United Kingdom found that 55% of emergency departments regularly use regional anesthesia techniques for hip and femur fractures.[18]

A 2002 Cochrane systemic review of nerve blocks for hip fractures undertaken shortly after admission to hospital concluded: “Nerve blocks resulted in statistically significant reductions in reported pain levels and in the quantity of parenteral or oral analgesia administered to control pain from the fracture or during surgery.”[19] Guidelines from the National Institute for Health and Clinical Excellence state, “Consider nerve block for additional analgesia or to limit opioid dosage.”[20]

Thus, lower limb peripheral nerve blocks may prove to be a useful tool in an anesthetists' armamentarium for not only improving perioperative patient comfort and reducing pain exaggerated by movements but also increasing the ease, success rate, and decreasing time for performing subarachnoid block.

The FNB results in anesthesia of the skin and muscles of the anterior thigh and most of the femur and knee joint.[11] The distribution of anesthesia and analgesia that is accomplished with the fascia iliaca block depends on the extent of the local anesthetic spread and the nerves blocked. The block should result in blockade of the femoral nerve in all instances (100%) and lateral cutaneous nerve of the thigh in 80%–100% instances.[11] The psoas muscle and pectineus muscle separate the obturator nerve from the femoral nerve along its course, and therefore, this nerve is not reliably blocked by FICB.[14] These blocks are well suited for surgery on the anterior thigh and knee, quadriceps tendon repair, and postoperative pain management after femur and knee surgery.

FNB and FICB were earlier performed using landmark or nerve stimulator technique, but advent of ultrasound overcame their shortcomings and is now a preferred technique. Several randomized control trials have also proved the superiority of ultrasound over other techniques.[7] Our study aims to compare FNB with FICB using USG technique as this remains unexplored.

Ropivacaine, the S-enantiomer of 1-propyl-2', 6'-pipecoloxylidide, was chosen because it has lower toxicity than the R-enantiomer. Reduced central nervous system and cardiac toxicity, along with lower lipid solubility which leads to less propensity for motor blockade than bupivacaine, has made ropivacaine one of the most commonly used long-acting local anesthetics in the peripheral nerve blockade.[21],[22],[23] Anupreet et al. also concluded that the onset of action of sensory and motor block was early in ropivacaine group with faster recovery of motor functions as compared to bupivacaine group.[24]

Our finding that FNB proves to be significantly more effective than FICB in reducing pain during positioning (sitting) for subarachnoid block was consistent with the study by Newman et al., who had postblock pain VAS score of 4.4 and 5.4 for FNB and FICB, respectively, using 0.5% levobupivacaine. They had mean reduction in pain VAS score of 3.7 and 2.8 for FNB and FICB, respectively (P = 0.05).[5] Somvanshi et al. had postblock pain VAS score of 1.84 for FNB with mean reduction in pain VAS score of 7.28 (P = 0.01) using 0.5% ropivacaine.[1] Kumar et al. had postblock pain VAS score of 2.94 for FICB with mean reduction in pain VAS score of 4.56 for (P = 0.01) using 0.5% ropivacaine.[4]

Deposition of ropivacaine within the vicinity of femoral nerve using ultrasound guidance that gives articular branches to hip joint increases the chances of the nerve getting block. This may be the reason why, in our study, the FNB proved to be more efficacious analgesic than FICB, which requires deposition of large volume of local anesthetic away from the femoral nerve.

We observed that FNB and FICB provided longer duration of postoperative analgesia compared to intrathecal 0.5% heavy bupivacaine alone which has a duration of 60–240 min.[24] It will not only decrease the use of systemic opiates and their adverse effects postoperatively but also delirium. This improves functional recovery and quality of life and decreases duration of hospital stay.[7]

Although our results were consistent with the previous studies, the use of ultrasonography for performing peripheral nerve blocks were the reasons for no failures and better perioperative patient comfort in our study.[1],[4],[5] Other reasons for no failures being stringent selection of cooperative patients, same anesthesiologist performing all the procedures, same assessor assessing the VAS score.

Hence, we recommend more widespread use of these USG lower limb blocks, especially FNB for perioperative analgesia and comfort during transfers, imaging, and patient positioning for patients with femur fractures.

In resource-limited hospital settings, FICB which is easy to learn and perform can be used as it also provides satisfactory analgesia and patient comfort.

Major limitations of our study included assessment of VAS score which is subjective and varies with the level of understanding between patient and anesthesiologist and assessment of comfort level that may vary from person to person as per their experience. Thus, objective assessment of these parameters may be difficult.

 Conclusion



USG FNB is more efficacious in reducing pain associated with positioning (sitting) for subarachnoid block in patients with fracture femur compared to USG FICB. It can be performed safely without complications, providing good patient comfort and longer duration of postoperative analgesia in the patients undergoing surgery for fracture femur.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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