Effect of early ultrasound-guided femoral nerve block on preoperative opioid consumption in emergency patients with hip fracture: a randomized trial

Abstract

Background and importance Ultrasound-guided femoral nerve block (FNB) could be used as part of a multimodal preoperative pain management for patients with hip fracture. Evidence of the effects of its early implementation in the emergency room as an immediate alternative to intravenous morphine titration is sparse. Objective To investigate the effect of an early ultrasound-guided FNB performed by emergency physicians on preoperative opioid consumption, compared to standard pain management. Design, setting, and participants This open randomized controlled trial was conducted in the Emergency Department of a French hospital with patients with neck or trochanteric femoral fracture who had a pain score ≥7 out of 10 points at triage. Intervention Patients were randomized to receive an initial analgesia with an early ultrasound-guided FNB or with standard pain management. The continuation of pain treatment followed standardized pain control guidelines until hospital discharge in both groups. Outcome measure and analysis The primary outcome was preoperative opioid consumption truncated 48h after triage time, and converted in morphine milligram intravenous equivalents (MME). Secondary outcomes were time to pain relief, time for regaining walk, opioid consumption and occurrence of opioid and FNB adverse effects during the hospital stay. Exploratory outcomes included ease and duration of the procedure. Main results We randomized 35 patients: 17 to standard pain management and 18 to ultrasound-guided FNB, among whom 30 patients completed the protocol. The median of preoperative opioid consumption was reduced by 60% in the ultrasound-guided FNB group compared to standard group [6 MME (3–9) vs. 15 MME (11–18)], with a consumption difference of 9 MME (95% CI: 3–14, P < 0.001). Throughout hospital stay, opioid consumption was reduced by 56% in the ultrasound-guided FNB group compared to standard group, with a consumption difference of 11.5 MME (95% CI: 0.5–22).Times to pain relief and for regaining walk did not differ between groups. Opioid adverse events occurrence were reduced by 40% (95% CI: 5.1–74.9) in the ultrasound-guided FNB group compared to standard group. No adverse effects of FNB have been detected. Conclusion Early ultrasound-guided FNB resulted in reducing preoperative opioid consumption, without delaying time to pain relief.

Authors’ reply to the comment on ‘Effect of early ultrasound-guided femoral nerve block on preoperative opioid consumption in patients with hip fracture: a randomized trial’

“…We thank Barik et al [1] for their interest in our randomized trial evaluating the effect of an early ultrasound-guided femoral nerve block (FNB) performed by emergency physicians on preoperative opioid consumption in patients with hip fracture [2]. To improve readers’ understanding, we respond below to their concerns or suggestions.…”

“…First, Barik et al . [1] pointed out that the study compared and analyzed the total opioid consumption throughout the hospital stay, and thus the title of the article was inappropriate. The title highlights the main result of this trial, that is, preoperative opioid consumption in both groups, truncated at the 48th of care after triage (mean surgical time: 2.4 ± 1.0 days).…”