Postoperative analgesia for fracture femur using Ultrasound-guided Fascia Iliaca block

INTRODUCTION

Fractures femur is one of the commonest fractures met in orthopedics and also the most shocking injuries of the elderly. It may be affecting any part like the shaft, distal (supracondylar), or proximal femur.¹ Subarachnoid anesthesia is one of the commonly applied anesthetic procedures, it is a regional anesthetic technique involved by injection of a local anesthetic (LA) in the subarachnoid space commonly in orthopedic surgeries.² Analgesia should be supplied throughout the perioperative period from the pre-hospital setting with mobilization.³ Fascia Iliaca block (FICB) was better in pain relief caused by fracture femur than opioids.⁴ Ultrasound guidance becomes the capital golden method for regional anesthesia. It improved safety and efficacy by minimizing the blind methods of side effects.⁵

The study aimed toevaluate the Visual Analog Scale (VAS) of patients undergoing femur fracture surgeries as a primary outcome and the secondary outcomes

PATIENT AND METHODS

This prospective randomized controlled clinical study was conducted on sixty patients, aged 30-50-year-old, with American Society of Anesthesiologists’ (ASA) physical status I–II conducted for Femur fractures admitted to the orthopedic department, this study was done between July and December 2019 in Samir Abbas hospital in Saudi Arabia after agreement of the local ethical committee and written informed consent. Patients were randomized using computer-generated closed and opaque sealed envelopes, assigned into two groups 30 patients in each group; Group (FICB)fascia iliaca block using ultrasonography (FICB) patients single shot with spinal anesthesia for fracture femur, while group (C) control group were handled with spinal anesthesia only.

Patient refusal, morbidly obese (BMI ≥40), Spine fractures, patient on anti coagulants, bleeding diathesis, and femoral grafts in the affected limb are excluded from this study. Once the patient in the operating room was connected to standard monitors; arterial blood pressure, electrocardiogram (ECG), and oxygen saturation (SpO2) (Drager, infinity delta XL, USA).  Intravenous Access must be secured before lumbar puncture is performed; then taken 10-20 ml/kg Ringer lactate solution and Visual analog scale for pain assessment was explained to all patients.

After aseptic preparation, patients were placed in the left lateral decubitus position and the skin was infiltrated with 2%lidocaine at (the L4-5 interspace). Spinal anesthesia was performed using a 25-gauge spinal needle (pencil point, B-Braun AG, Germany). Cerebrospinal fluid free flow obtained then 15 mg 0.5% hyperbaric bupivacaine (aspen pharma, Ireland) was injected intrathecally over 20-30 sec, and this technique was done for the two groups.

In (FICB) group: After the end of the surgery, A sterile field is established with Betadine solution skin is disinfected and (Under aseptic condition). Palpation of a femoral artery may be a good landmark then the high frequency linear superficial probe was put transversely on the inguinal crease, moving slowly medially or laterally to find the iliacus muscle, fascia iliaca, and fascia lata. Using in the plane approached a 22 Gauge echogenic needle (sonolex Stim Pajunk) was inserted from the lateral side the two fascia clicks are perceived consecutively when the needle penetrating fascia lata and reach the plane between it and fascia iliaca. Negative aspiration: and then 1 to

 2 mL of local anesthetic was injected to confirm the proper injection site between the fascia and the iliopsoas muscle. If local anesthetic spread takes place above the fascia or within the substance of the muscle itself, additional needle repositions, and injections were done. Complete the ultrasound fascia iliaca Block: by injected 30-mL of local anesthetic 0.5 % (Isobaric bupivacaine) (Bucaine 0.5% 5mg/ml, HIKMA Pharmaceutical, Amman-Jordan).

A proper injection will result in the separation of the fascia Iliaca from the iliopsoas muscle by the local anesthetic which spreads lateral towards the anterior superior iliac spine and medially towards the femoral nerve as shown in (Figure 1).

The pain assessment postoperative was performed using (VAS) (0- no pain and 10 cm is the maximum agony).⁶

All our patients assessed for pain using (VAS). Pain assessment using VAS did postoperative after finishing the procedure at 0 points (the full recovery state), 2 hr, 6 hr, 12 hr, and 24 hr. Morphine sulfate 0.03mg/kg as rescue analgesia was given if needed, when VAS ≥ 4 in the post-operative 24 hours or on patient’s demand (morphine sulfate 10mg/ml, Martindale pharmaceutical, UK). The total amount of morphine boluses in the first postoperative 24hours and the time of first analgesic dose of morphine received post-operative was calculated.

Mean arterial blood pressure (MABP) was assessed post-operatively at 0 points (immediately after the procedure), 2 hr, 6 hr, 12 hr, and at 24 hr. Complications occur postoperatively as nausea, vomiting, and pruritus were recorded. Patient satisfaction related to block performance, post-operative pain relief was evaluated by an 11- point satisfaction score (0=unsatisfied and 10 = most satisfied) ⁷, and the score was divided as follows 0-3 (not satisfied), 4-6 (fair), and 7-10 (good).

Statistical analysis:  Analysis was done using SPSS file software package for social science, quantitative data are expressed is frequencies, percentage, and the results carried out for analysis using descriptive t-tests and chi-square tests to compare continuous variables and categorical data respectively. A P-value of less than 0.05 was considered significant.

RESULTS

There was no significant difference between the two studied groups regarding patients’ characteristics, ASA, site of the fracture, and baseline clinical status (𝑃>0.05) as shown in (Table 1).

In this study, regarding the measurement of VAS, there was a highly significant difference with p<0.001) between the FICB group and the control group at  4h,6h,12h, and 24h postoperatively as shown in (Table 2). Regarding postoperative MAP measurement, there was no significant difference between the two studied groups (p-value >0.05) as shown in (Table 3).

Measurements of the first analgesic dose received post-operative showed that: Control group 223.75 ± 15.829min earlier than the FICB group 480.833 ± 41.222min and the total amount of morphine used with control group 11.917 ± 2.937mg higher than the total amount of morphine used with FICB group study group 6.417 ± 1.929mg see (Table 4).. There was a significantly longer time for the demand for the 1st dose of analgesia in FICB group compared to the control group. Also, the FICB group showed the most prolonged duration of analgesia and the least analgesia consumption (mg) during the first twenty-four hours postoperative as shown in (Table 4).

In this study, regarding complications, more complications occurred in the control group compared to FICB group with a significant difference between the two studied groups (p-value ˂0.001) as shown in (Table 5). In this study, regarding Patients satisfaction measurement, more patients were highly satisfied in group FICB (73%) than the control group (16.7%) (P ˂0.001) as shown in (Table 6).

Fig 1: Ultrasound image showing local anesthetic extent within a left fascia iliaca and the femoral nerve.

Table 1: Demographic data, ASA, and fracture site (Mean ± SD, p value

Table 2: Visual Analog Score (VAS) among the two studied groups. (VAS: visual analog scale, IQR: interquartile range), (*: Statistically significant (p-value <0.05).

Table 3: Comparison between the two studied groups according to Mean arterial blood pressure (mmHg). (Mean ±SD, p value>0.05 non-significant).

Table 4: Time up to the 1st dose of rescue analgesia and total morphine consumption during the first 24 hrs. Mean ± SD, p value (< 0.05) significant.

Table 5: complications that happened during the study. (Mean ±SD, p-value < 0.05 significant).

Table 6: Patient satisfaction. (Mean ± SD, p value < 0.05 significant).