A multi-institutional prospective observational study to evaluate fascia iliaca compartment block (FICB) for preventing delirium in adults with hip fracture

Abstract

ObjectivesUntil recently, systemic opioids have been standard care for acute pain management of geriatric hip fracture; however, opioids increase risk for delirium. Fascia Iliaca compartment blocks (FICB) may be favored to systemic analgesia for reducing delirium, but this has not been well demonstrated. We evaluated the efficacy of adjunctive FICB versus systemic analgesia on delirium incidence, opioid consumption, and pain scores.MethodsThis prospective, observational cohort study was performed in patients (55–90 years) with traumatic hip fracture admitted to five trauma centers within 12 hours of injury, enrolled between January 2019 and November 2020. The primary end point was development of delirium, defined by the Confusion Assessment Method tool, from arrival through 48 hours postoperatively, and analyzed with multivariate Firth logistic regression. Secondary end points were analyzed with analysis of covariance models and included preoperative and postoperative oral morphine equivalents and pain numeric rating scale scores.ResultsThere were 517 patients enrolled, 381 (74%) received FICB and 136 (26%) did not. Delirium incidence was 5.4% (n=28) and was similar for patients receiving FICB versus no FICB (FICB, 5.8% and no FICB, 4.4%; adjusted OR: 1.2 (95% CI 0.5 to 3.0), p=0.65). Opioid requirements were similar for patients receiving FICB and no FICB, preoperatively (p=0.75) and postoperatively (p=0.51). Pain scores were significantly lower with FICB than no FICB, preoperatively (4.2 vs 5.1, p=0.002) and postoperatively (2.9 vs 3.5, p=0.04).ConclusionsFICB demonstrated significant benefit on self-reported pain but without a concomitant reduction in opioid consumption. Regarding delirium incidence, these findings suggest clinical equipoise and the need for a randomized trial.Level of evidenceII—prospective, therapeutic.

Does time to surgery for traumatic hip fracture impact the efficacy of fascia iliaca blocks? A brief report

“…Current practice is to prescribe non-opioid medications and to increase opioids (per oral then intravenous) once the patient’s pain is not adequately controlled based on self-reported pain scores. We did not evaluate non-opioid analgesics as part of multimodal pain management in this analysis; when they were examined in the main prospective study, we found no differences in their administration between FICB and no FICB groups 3…”

“…We did not evaluate non-opioid analgesics as part of multimodal pain management in this analysis; when they were examined in the main prospective study, we found no differences in their administration between FICB and no FICB groups. 3 …”

“…We did not evaluate non-opioid analgesics as part of multimodal pain management in this analysis; when they were examined in the main prospective study, we found no differences in their administration between FICB and no FICB groups. 3 The search for the appropriate balance between adequate pain analgesia and avoiding the dire side effects of narcotic use continues to plague the medical community. In our effort to shed more light on this subject, we studied the effects of surgical timing on FICB and pain outcomes.…”

“…We recently completed a prospective, multicenter, observational cohort study of patients with a traumatic hip fracture requiring surgery to examine the efficacy of fascia iliaca compartment blocks (FICBs) 3. Compared with patients receiving systemic analgesia, patients with an FICB had lower self-reported pain, but there were no differences in opioid use or complications including development of delirium.…”

Time to adequately heed Acute Pain in the Emergency Department – More Regional Blocks Warranted

“…Even though the elderly usually suffers a hip fracture after a minor trauma, the consequences are major. For the geriatric patient, who often show multi-morbidity and ger iatr ic sy ndromes (i.e., frai lt y, malnutr ition, polypharmacy, cognitive impairment, and mental disorders), these fractures result in: a) higher mortality rates of 8-10% in the first 30 days and 15-30% within the first year of the hip fracture (Verbeek 2021); b) longer length of stay (LOS); reduced quality of life with 10% of patients never returning to their own residence, but to alternative long-term care as they become dependent of care takers [6] and d) a high incidence of postoperative delirium, ranging from 4 to 53%, which is the most common complication of hip fracture surgery and which is also associated with a higher mortality rate [6][7][8][9][10]. Furthermore, hip fractures are one of the most expensive clinical conditions with huge costs related, estimated at 20 billion US$ spent annually on this injury and about 1% of the annual NHS budget in the UK [11].…”