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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 36  |  Issue : 3  |  Page : 135-139

Comparison of efficacy of fascia iliaca compartment block using ropivacaine versus ropivacaine with dexmedetomidine versus ropivacaine with dexamethasone for acute pain relief in patients with femoral fractures: A prospective randomized controlled study


Department of Anaesthesiology, Mahatma Gandhi Memorial Medical College, Indore, Madhya Pradesh, India

Date of Submission22-Mar-2022
Date of Decision13-May-2022
Date of Acceptance18-May-2022
Date of Web Publication21-Nov-2022

Correspondence Address:
Dr. Minanshu Mittal
Room No. 46, PG Block, MGM Medical College Boys Hostel, White Church, Indore - 452 001, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_32_22

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  Abstract 


Context: Landmark-guided fascia iliaca compartment block (FICB) has been used in operation theater to facilitate patient position before administration of subarachnoid block, but its utilization is yet to be explored in the accident and emergency department for acute pain relief in patients with femoral fractures. Aims: The study aims to compare dexmedetomidine and dexamethasone as adjuvants to ropivacaine for FICB for onset and duration of analgesia. Settings and Designs: This was a prospective randomized controlled study performed in Mahatma Gandhi Memorial Medical College, Indore. Subjects and Methods: Ninety patients with femoral factures were allocated into three groups, and each group received 15 ml of study drug; (i) ropivacaine with dexmedetomidine (RD) group (0.2% ropivacaine with 50 μg dexmedetomidine), (ii) ropivacaine with dexamethasone (RM) group (0.2% ropivacaine with 4 mg dexamethasone), and (iii) ropivacaine alone (RP) group (0.2% ropivacaine). Patients were assessed for onset, duration of analgesia, and need for rescue analgesic. Severity of pain was assessed using Numerical Rating Scale (NRS) score. Statistical Analysis Used: Comparison of means of three groups was done using One-Way ANOVA and pair-wise comparisons using post hoc Tukey's test. Results: The onset of analgesia was earlier in Group RD at 4.38 min followed by Group RM at 4.45 min and Group RP at 7.86 min, whereas the duration of analgesia was longer in Group RD at 725 min followed by Group RM at 594 min and Group RP at 275 min. NRS Score was comparable before application of FICB. After the block, the mean NRS score in Group RD was 3.83, in Group RM was 5.30, and in Group RP was 7.93. Conclusions: FICB is an effective alternative to intravenous opioids and nonsteroidal anti-inflammatory drugs for acute pain relief in patients with femoral fractures, and dexmedetomidine and dexamethasone can be used as adjuvants to ropivacaine as they both enhance quality of block.

Keywords: Dexamethasone, dexmedetomidine, fascia iliaca compartment block, femoral fractures, Numerical Rating Scale, ropivacaine


How to cite this article:
Arora KK, Pauranik R, Mittal M. Comparison of efficacy of fascia iliaca compartment block using ropivacaine versus ropivacaine with dexmedetomidine versus ropivacaine with dexamethasone for acute pain relief in patients with femoral fractures: A prospective randomized controlled study. Indian J Pain 2022;36:135-9

How to cite this URL:
Arora KK, Pauranik R, Mittal M. Comparison of efficacy of fascia iliaca compartment block using ropivacaine versus ropivacaine with dexmedetomidine versus ropivacaine with dexamethasone for acute pain relief in patients with femoral fractures: A prospective randomized controlled study. Indian J Pain [serial online] 2022 [cited 2022 Dec 2];36:135-9. Available from: https://www.indianjpain.org/text.asp?2022/36/3/135/361624




  Introduction Top


The incidence of road traffic accidents leading to fracture pelvis and femur is very high in India. Almost 21% of all the fractures at hip joint are due to road traffic accidents.[1] Similarly, fall from standing height and osteoporosis[1],[2] induced fractures of these bones are common in old age and constitute almost 76% of all the fractures encountered. These patients upon arriving in the accident and emergency (A&E) department have to undergo radiological investigations and orthopedic procedures such as reduction of fracture and application of traction.[3] However, due to pain and distress, it becomes difficult for these patients to cooperate.

Pain treatment is conventionally based on systemic opioids and other parenterally administered drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), which have a large potential for side effects.[4],[5] Landmark-guided fascia iliaca compartment block (FICB)[6] is a technique which has been used in operation theater to facilitate patient position before administration of subarachnoid block, but its utilization is yet to be explored in the A&E department for acute pain relief in these patients. Performing FICB with local anesthetic alone provides analgesia for short duration of time and needs administration of supplemental analgesics thereafter. To overcome this limitation, various adjuvants such as dexamethasone, dexmedetomidine, and clonidine have been added to plain local anesthesia to improve the quality of block and duration of analgesia.[7],[8]

In A&E department, anesthesiologist's role is limited as of now when it comes to pain management of patients presenting with pain. Our study aims to provide adequate analgesia to the patients presenting with femoral fractures using landmark-guided FICB and to compare the efficacy of block using ropivacaine versus ropivacaine with dexmedetomidine (RD) versus ropivacaine with dexamethasone (RM) with regard to analgesic effects and adverse effects.

Aims and objectives

To compare dexmedetomidine and dexamethasone as an adjuvant to ropivacaine and ropivacaine alone (RP) in patients undergoing FICB for:

  1. Onset of analgesia
  2. Duration of analgesia
  3. Hemodynamic variations.



  Subjects and Methods Top


A prospective randomized controlled study was conducted on 90 patients presenting to the A&E Department with femoral fractures. Patients with American Society of Anesthesiologists (ASA) Physical Status I and II, aged from 18 to 80 years of either sex with femoral fractures were included in the study. Patients with infection at the site of block, uncorrectable bleeding disorder, allergic to local anesthetic agents, or having any neurological or psychiatric illness were excluded from the study.

After approval from the Institutional Ethics Committee, the patients were randomly allocated equally into three groups, i.e., Group RD, Group RM, and Group RP with 30 patients in each group. Intravenous line was secured in all patients and was connected to multiparameter monitor for monitoring of heart rate, oxygen saturation, noninvasive blood pressure, and electrocardiogram.

Informed consent was obtained from all patients. Baseline Numerical Rating Scale (NRS) score, Ramsay Sedation Score, and hemodynamic parameters were noted before the procedure. Patients were then administered FICB by landmark-guided technique in supine position. Anterior superior iliac spine and pubic tubercle were marked on the affected side, and a line was drawn between them; this line marked the inguinal ligament which was then divided into equal thirds and a point was marked at the junction of lateral one-third and medial two-thirds. Insertion point was marked 1 cm distal to the above point. Skin at the site of needle insertion was prepared with antiseptic solution, draped, and infiltrated with 1.5 ml of 1% injection (inj.) lignocaine adrenaline solution in the subcutaneous plane.

Twenty-two-gauze intravenous cannula was used to pierce the skin at the marked point. Needle was advanced in the sagittal plane to avoid the neurovascular bundle which is located medially. Two distinct pops were felt as the needle perforated; first, the fascia lata, and then, the fascia iliaca. Needle was further advanced 1–2 mm. If aspiration was negative, drug was injected. There was no resistance to injection. Drug was injected slowly, aspirating after every 5 ml up to a total of 15 ml.

  • Thirty patients in Group RD received 14 ml of 0.2% ropivacaine and 50 μg dexmedetomidine (total volume 15 ml)
  • Thirty patients in Group RM received 14 ml of 0.2% ropivacaine and 4 mg dexamethasone (total volume 15 ml)
  • Thirty patients in Group RP received 15 ml of 0.2% ropivacaine, without any adjuvants.


Needle was withdrawn after the injection and pressure was applied distally for 2–3 min.

Patients were assessed at 5 min interval for the first 15 min, then at an interval of 1 h for the next 4 h, and then at 8, 12, 16, 20, and 24 h after the procedure. NRS score and vital parameters such as heart rate, oxygen saturation, and mean arterial pressure were recorded. At any time during the study, if the NRS score was 4 or > 4, inj. tramadol 2 mg per kg was given by slow intravenous infusion as a rescue analgesic. Time at which first rescue analgesic was administered and its total dose given were noted carefully.


  Results Top


Thirty patients were taken in each group for this study. A total of 90 patients were thus analyzed, and the following results were obtained. The groups were well matched regarding age, gender, and the ASA status [Table 1].
Table 1: Demographic profiles of patients

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The mean onset of analgesia [Graph 1] was earlier in Group RD at 4.38 ± 0.31 min, followed by Group RM at 4.45 ± 0.30 min, and was most delayed in Group RP at 7.86 ± 0.90 min, and the difference was statistically significant among the three groups (P < 0.050), whereas the mean duration of analgesia [Graph 2] was significantly longer in Group RD at 725.67 ± 42.81 min, followed by Group RM at 594.00 ± 34.09 min, and was shortest in Group RP at 275.33 ± 18.93 min. The difference among the three groups was statistically significant (P < 0.05).



In our study, NRS was used to assess the severity of pain and patients were asked to rank the pain from 0 to 10 in increasing order. The mean NRS score on arrival in the A&E department in Group RD was 8.73 ± 0.64, in Group RM was 8.77 ± 0.57, and in Group RP was 8.43 ± 0.57 (P = 2.85), which was comparable among three groups. At 5 min after the block, the mean NRS in Group RD was 3.83 ± 1.15, in Group RM was 5.30 ± 2.48, and in Group RP was 7.93 ± 1.29. As the onset of action was earlier in Group RD and Group RM, pain score decreased rapidly as compared to that of Group RP. 10 min after the FICB, the mean NRS score in Group RD decreased to 0.27 ± 0.94, in Group RM decreased to 1.37 ± 2.20, and in Group RP came down to 3.23 ± 1.30. Ten minutes after the block, NRS score fell significantly in Group RP from 7.93 ± 1.29 to 3.23 ± 1.30 as the mean onset of analgesia was 7 min 52 s [Graph 3].



Sixty-seven percent of patients did not require rescue analgesics up to 8 h following administration of FICB, whereas 33% of patients required rescue analgesia. In 8–12 h following administration, 67% of the patients required rescue analgesics, whereas only 33% of patients did not require administration of rescue analgesics. Requirement of rescue analgesics was highest in Group RP (mean 2.53 ± 0.09), whereas it was comparable in Group RD (mean 1.47 ± 0.51) and Group RM (mean 1.63 ± 0.49).

Group RP had higher pulse rate in comparison to Group RD and Group RM, whereas it was was comparable between Group RD and Group RM at all time intervals after the procedure. The mean pulse rate was within normal acceptable range. The patients in Group RD and Group RM did not experience any pain till 8 h after the procedure, while in Group RP, the patients were pain free only till 4 h after the administration of FICB. None of the patients experienced any adverse effects during the course of study.


  Discussion Top


Patients with femoral fractures are being encountered in increasing numbers nowadays in the A&E department because of increase in road traffic accidents. Furthermore, it is more common in the elderly due to reduction in bone mineral density and coexisting osteoporosis. These patients often suffer from intolerable pain and anxiety. The aim of this study was to provide adequate analgesia to the patient with femoral fractures in the A&E department immediately after arrival so that the patient is made comfortable and cooperates well for radiological investigations, transportation, and application of traction. Landmark-guided FICB is easy to perform, is inexpensive, and is not associated with adverse effects. Local anesthetic agent ropivacaine is used as it is a long-acting amide with better safety profile as compared to bupivacaine. As it is less lipophilic, penetration of large myelinated motor fibers is less, resulting in reduced motor blockade.[9],[10]

Dexmedetomidine is highly selective for alpha 2 adrenergic receptors and acts as an agonist. It causes hyperpolarization of nerve tissues by alteration of transmembrane potential and ion conductance, thereby causing enhancement of local anesthetic effects. Because of its tendency to enhance sympathoadrenal stability, it prolongs the duration of analgesia and provides rapid onset of action.[11]

Dexamethasone is a synthetic, long-acting corticosteroid with potent anti-inflammatory properties.[12] Analgesic effect of dexamethasone is due to local anesthetic action of corticosteroids, and it acts by reducing ectopic neuronal discharge and inhibiting potassium channel-mediated discharge of nociceptive C fibers.

In this study, we found that the onset of analgesia was shortest in Group RD at 4.38 ± 0.31 min, followed by Group RM at 4.45 ± 0.30 min, and was longest in Group RP at 7.86 ± 0.90 min [Graph 1]. The findings that addition of dexmedetomidine or dexamethasone as adjuvants to ropivacaine quickens the onset of analgesia which is also comparable with the results of studies performed by Kumar et al.,[13] Somvanshi et al.,[3] and Adinarayanan et al.[14]

Ten minutes after the FICB, the mean NRS in Group RD decreased to 0.27 ± 0.94, in Group RM decreased to 1.37 ± 2.20, and in Group RP came down to 3.23 ± 1.30.

Lopez et al.[15] performed FICB with 1.5% lidocaine and epinephrine and found that Simplified Verbal Scale score was 3 before the application of block, and it decreased to 1, 10 min after the block, and later reduced to 0 when patient arrived to trauma care center. Kumar et al.[13] found that NRS score reduced significantly in both ropivacaine group (Group R) and dexmedetomidine group (Group D) after 10 min of block, but it was seen that fall in NRS score was more rapid in Group D as addition of dexmedetomidine as adjuvant caused faster onset of analgesia as compared to RP. At 8 h after the procedure, NRS score increased to 4.97 ± 0.85 in Group RP, whereas it remained 0 in Group RD and Group RM. Then, at 12 h, the mean NRS score in Group RD was 1.33 ± 1.89, in Group RM was 4.77 ± 0.82, and in Group RP was 5.63 ± 0.96. At 16 h, the mean NRS in Group RD was 3.97 ± 1.19 and in Group RM was 4.07 ± 0.94. The difference was statistically not significant (P > 0.05).

Adequate analgesic effect in Group RD remained till 725.67 ± 42.81 min and in Group RM was 594.00 ± 34.09 min [Graph 2]. Kumar et al.[13] in their study found that the total duration of analgesia was 744.33 ± 179.6 min in Group D compared to 263.1 ± 67.24 min in Group R. Addition of dexmedetomidine as an adjuvant to ropivacaine significantly prolonged the duration of analgesia which was evident from the results obtained in our study. Addition of adjuvants reduced the requirement of rescue analgesics significantly as compared to that to the group in which FICB was performed using RP.

Significant fall in the mean pulse rate was found in all the three groups compared to base values, and it was more profound in Group RD as compared to Group RM and Group RP. It might be due to the systemic absorption of dexmedetomidine and increased sedation associated with it. Mean arterial pressure remained in the range of 85–95 mmHg, and no significant difference was noted between three groups.


  Conclusions Top


On the basis of the results and observations obtained from this study, it can be concluded that FICB provides adequate pain relief within few minutes of application and is not associated with any adverse effects and hence can be considered as an alternative option to intravenous NSAIDs and opioids for acute pain relief in the A&E department. Dexmedetomidine (50 μg) or dexamethasone (4 mg) can be used as adjuvants to ropivacaine for FICB as they prolongs the duration of analgesia and are not associated with any adverse effects.

Limitations

Although this study has tried to meet its aims and objectives in all aspects, there are few limitations to it: First, we conducted a single-center study, and second, patients with multiple or compound fractures were not included in our study. To overcome these limitations, a multicenter study with larger sample size is needed to obtain more conclusive results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
George J, Sharma V, Farooque K, Mittal S, Trikha V, Malhotra R. Injury mechanisms of hip fractures in India. Hip Pelvis 2021;33:62-70.  Back to cited text no. 1
    
2.
Mittal R, Banerjee S. Proximal femoral fractures: Principles of management and review of literature. J Clin Orthop Trauma 2012;3:15-23.  Back to cited text no. 2
    
3.
Somvanshi M, Tripathi A, Meena N. Femoral nerve block for acute pain relief in fracture shaft femur in an emergency ward. Saudi J Anaesth 2015;9:439-41.  Back to cited text no. 3
    
4.
Wongrakpanich S, Wongrakpanich A, Melhado K, Rangaswami J. A comprehensive review of non-steroidal anti-inflammatory drug use in the elderly. Aging Dis 2018;9:143-50.  Back to cited text no. 4
    
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Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N, et al. Opioid complications and side effects. Pain Physician 2008;11 Suppl 2:S105-20.  Back to cited text no. 5
    
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Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg 1989;69:705-13.  Back to cited text no. 6
    
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Kirksey MA, Haskins SC, Cheng J, Liu SS. Local anesthetic peripheral nerve block adjuvants for prolongation of analgesia: A systematic qualitative review. PLoS One 2015;10:e0137312.  Back to cited text no. 7
    
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Abdallah FW, Brull R. Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: A systematic review and meta-analysis. Br J Anaesth 2013;110:915-25.  Back to cited text no. 8
    
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Graf BM, Abraham I, Eberbach N, Kunst G, Stowe DF, Martin E. Differences in cardiotoxicity of bupivacaine and ropivacaine are the result of physicochemical and stereoselective properties. Anesthesiology 2002;96:1427-34.  Back to cited text no. 9
    
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Kuthiala G, Chaudhary G. Ropivacaine: A review of its pharmacology and clinical use. Indian J Anaesth 2011;55:104-10.  Back to cited text no. 10
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11.
Brummett CM, Norat MA, Palmisano JM, Lydic R. Perineural administration of dexmedetomidine in combination with bupivacaine enhances sensory and motor blockade in sciatic nerve block without inducing neurotoxicity in rat. Anesthesiology 2008;109:502-11.  Back to cited text no. 11
    
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Liu K, Hsu CC, Chia YY. Effect of dexamethasone on postoperative emesis and pain. Br J Anaesth 1998;80:85-6.  Back to cited text no. 12
    
13.
Kumar H, Tripathi A, Somvanshi M. Efficacy of Dexmedetomidine as an adjuvant to Ropivacaine in femoral nerve block for acute pain relief in patients with fracture of femoral shaft and neck. Indian J Pain 2018;32:86-90.  Back to cited text no. 13
    
14.
Adinarayanan S, Chandran R, Swaminathan S, Srinivasan G, Bidkar PU. Comparison of Dexamethasone and Dexmedetomidine as adjuvants to bupivacaine in supraclavicular brachial plexus block: A prospective randomized study. Indian J Clin Anaesth 2019;6:523-7.  Back to cited text no. 14
    
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Lopez S, Gros T, Bernard N, Plasse C, Capdevila X. Fascia iliaca compartment block for femoral bone fractures in prehospital care. Reg Anesth Pain Med 2003;28:203-7.  Back to cited text no. 15
    



 
 
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