Pain treatment in post-traumatic hip fracture in the elderly: regional block vs. systemic non-steroidal analgesics

Abstract

BackgroundThis prospective, randomized double-blind study, conducted over 19 months in a tertiary care ED, sought to determine if a fascia-iliaca regional anesthetic block provides better and safer pain relief than does parenteral analgesia.AimsThis study also aimed to determine the effectiveness of parenteral NSAID analgesia for acute hip fractures.MethodsPatients >65 years old presenting at an adult ED with acute hip fractures were randomized upon presentation to the ED into two groups (A and B) using numbers generated by the EPI-INFO™ (Atlanta, GA: Centers for Disease Control and Prevention) program. The randomization list was kept by one of the authors who did not interact with the patients. Two groups of patients were to receive either (A) a fascia-iliaca block with bupivacaine and parenteral saline injection, or (B) the same block with saline and an IV NSAID injection. Upon admission to the study, vital signs such as blood pressure, mean blood pressure (MAP), heart rate (HR), respiratory rate (RR) and pain-intensity measurements [using the Visual Analogue Scale (VAS)] were obtained and repeated at 15 min, 2 h and at8 h. The occurrence of complications was registered.ResultsOne hundred seventy-five patients were randomized, and 21 were excluded from participation. The remaining 154 patients were grouped as: group A (n = 62) or group B (n = 92). The mean pain level on admission to the ED for all patients, assessed with the VAS, was 8.21 ± 0.91 (CI 95%: 6.43–9.99); in group A the VAS was 7.6 ± 0.22 and in group B 8.5 ± 0.72 (p = 0.411). At 15-min evaluation, values were: group A 6.24 ± 0.17 and group B 2.9 ± 0.16 (p < 0.001). At the 2-h assessment, values were: group A 1.78 ± 0.11 and group B 2.3 ± 1.16 (p = 0.764). At 8 h the VAS for group A was 2.03 ± 0.12 and for group B 4.4 ± 0.91 (p = 0.083).ConclusionThis study demonstrates that: (1) parenteral NSAIDs are very effective as analgesics after hip fractures in elderly patients, (2) fascia-iliaca regional blocks are nearly as effective for up to about 8 h after administration and (3) regional fascia-iliaca blocks effectively control post-hip fracture pain. (4) Fascia iliaca regional block has a rapid onset.

Efficacy of supplemental peripheral nerve blockade for hip fracture surgery: multiple treatment comparison

“…The estimate for pain intensity change was SMD -2.0 (95% CrI -3.81 to -0.25), and it had the highest probability of being the best choice for pain relief. Fascia iliaca block, studied in three trials 22,30,31 comprising 453 patients, was the next best choice on probability grounds, but its effect size for pain relief did not reach statistical significance. Fig.…”

“…Overall, 1 (5%) RCT 15 was assessed as low risk of bias, 9 (43%) 14,[16][17][18][19][20][21][22][23] had high risk of bias, and the remaining 11 (52%) 13,[24][25][26][27][28][29][30][31][32][33] The Table lists key characteristics of the eligible studies. They were published from 1991 to 2010 and ranged in size from 14-209 participants.…”

“…We were able to compare acute pain intensity between seven nerve block strategies using data from 16 studies comprising 1,089 subjects. In 15 studies, pain was measured on a 10-cm visual analogue scale or an 11-point numeric rating scale, 13,16,17,[20][21][22][23][24][25]27,28,[30][31][32][33] and in one study, a four-point verbal rating scale was used. 18 Pain was also measured at a variety of intervals (ranging from hourly to daily).…”

“…The criteria used for the diagnosis of delirium were not reported in three studies. 15,19,30 In one study, 16 the Mini Mental State Examination (MMSE) was used, but the change in MMSE necessary to define delirium was not provided. In one other trial, 31 daily MMSE and two other instruments were used to diagnose delirium against the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria.…”

Continuous Femoral Nerve Block Versus Fascia Iliaca Compartment Block as Postoperative Analgesia in Patients with Hip Fracture

“…They have no side-effects as do opioid analgesics, but can cause damage to the gastrointestinal mucosa, renal tubules and platelet dysfunction, and can increase intraoperative bleeding [9,10].…”