BackgroundPost-operative cognitive impairment is common in elderly patients following surgery for hip fracture, with undertreated pain being an important etiological factor. Non-opioid based analgesic techniques, such as nerve blocks, may help reduce the risk of cognitive complications. The aim of this study was to investigate whether receiving a fascia iliaca compartment block (FICB) as part of a pre-operative analgesic regime increased the odds of high post-operative abbreviated mental test scores (AMTS) when compared with conventional analgesia without a nerve block.MethodsA retrospective data analysis of a cohort of 959 patients, aged ≥ 65 years with a diagnosis of hip fracture and admitted to a single hospital over a two-year period was performed. A standardized analgesic regime was used on all patients, and 541/959 (56.4%) of included patients received a FICB. Provision of the FICB was primarily determined by availability of an anesthetist, rather than by patient status and condition. Post-operative cognitive ordinal outcomes were defined by AMTS severity as high (score of ≥9/10), moderate, (score of 7–8) and low (score of ≤6). A multivariable ordinal logistic regression analysis was performed on patient status and clinical care factors, including admission AMTS, age, gender, source of admission, time to surgery, type of anesthesia and ASA score.ResultsAdmission FICB was associated with higher adjusted odds for a high AMTS (score of ≥9) relative to lower AMTS (score of ≤8) than conventional analgesia only (OR = 1.80, 95% CI 1.27–2.54; p = 0.001). Increasing age, lower AMTS on admission to hospital, and being admitted from a residential or nursing home were associated with worse cognitive outcomes. Mode of anesthesia or surgery did not significantly influence post-operative AMTS.ConclusionPost-operative AMTS is influenced by pre-operative analgesic regimes in elderly patients with hip fracture. Provision of a FICB to patients on arrival to hospital may improve early post-operative cognitive performance in this population.

Background: Fascia iliaca compartment block (FICB) is an increasingly popular analgesic technique in elderly patients with hip fracture. Despite requiring large volumes of local anaesthetic, there is no safety data on plasma concentration of local anaesthetic after FICB in elderly patients. Objectives: The aim was to determine the safety and pharmacokinetic profile of a 75 mg levobupivacaine (30ml 0.25%) FICB dose in patients aged ≥80 years with a fractured neck of femur. Methods: This was a single-arm descriptive study. 12 adults, aged ≥80 years and admitted to hospital with hip fracture, received FICB performed under ultrasound guidance. Venous blood was sampled at 10, 20, 30, 45, 60, 75, 90, 105, 120 and 240 minutes after injection. Total plasma levobupivacaine concentration was measured by mass spectrometry method. Main outcome measures were pharmacokinetic parameters, including maximum observed plasma concentration (Cmax), time to reach Cmax (tmax) and area under the plasma concentration-time curve (AUC). Results: Median (IQR) Cmax was 0.82 μg.ml-1 (0.47-1.03). tmax was 45 minutes (41:20-60:00). No evidence of toxicity was identified. Plasma levobupivacaine concentrations were below the threshold associated with toxicity in younger, healthy patients (2.6 μg.ml-1). No association was found between individual patient Cmax and α1 acid glycoprotein, weight, or body mass index. Conclusions: Absorption of levobupivacaine was slow and all patients had plasma concentrations below the toxic threshold. This pharmacokinetic analysis supports the safety and efficacy of FICB in elderly patients with hip fracture. Clinical trial registration: ISRCTN27364035 (UK Clinical Trials Gateway) 3 Key points  Use of fascia iliaca compartment block in elderly patients is safe, well tolerated and effective in reducing pain associated with a fractured neck of femur.  Following administration of a 75mg dose of levobupivacaine via a fascia iliaca compartment block, systemic absorption of local anaesthetic into the plasma is slow (tmax 45 minutes).  No relationship was observed between Cmax and α1 acid glycoprotein, weight, or body mass index.

Using the database of our pain management team, we examined the records of 254 patients weighing between 4.5 kg and 10 kg who received an epidural for postoperative analgesia. We looked at the incidence of catheter related problems in two groups of patients in whom either a 21-G (18-G short Tuohy needle) or a 23-G catheter (19-G short Tuohy needle) was used. There was a significantly higher incidence of difficulty in threading the catheter, kinking and occlusion in the 23-G catheter group. There were more leaks in the 21-G catheter group but the difference was not significant and both groups had a comparable incidence of clinically relevant leakages. No dural tap or difficulty in using either needle were reported.

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