Psoas compartment block efficacy and safety for perioperative analgesia in the elderly with proximal femur fractures: a randomized controlled study

Abstract

Background Proximal femur fractures are most common fractures in the elderly and associated with significant mortality and morbidity, with high economic and social impact. Perioperative pain management influence outcomes and mortality after surgery with early mobilization being possible. The goal of the study was to compare the efficacy and safety of the psoas compartment block (PCB) with spinal and general anesthesia. Methods We included 90 patients in this randomized controlled study and divided them into three groups. For patients in group 1 ultrasound-guided PCB with bupivacaine 0.125% 6–8 ml / h was performed. Intraoperative anesthesia was provided with PCB and a sciatic nerve block. Postoperative analgesia include prolonged CPB with bupivacaine 0.125% 6–8 ml / h. In group 2 intraoperative spinal anaesthesia were performed. Group 3 patients underwent general sevoflurane inhalation anaesthesia with fentanyl infusion for analgesia. All patients received paracetamol 3 g/day and dexketoprofen 75 mg/day during hospitalization. On-demand, nalbuphine 5 mg SC was used for analgesia. Efficacy outcomes were the ICU length of stay and the total duration of hospitalization, number of patients who had severe pain after surgery, incidence of on-demand analgesia, sleep quality, postoperative mobilization time. Safety outcomes include complication incidence. Results There were no differences in the duration of ICU stay - gr.1 72 [70–75], gr.2 74 [72–76], gr.3 72 [70–75] hours respectively (p = 0.29), and the total duration of hospitalization - gr.1144 [170–184], gr.2170 [148–188], gr.3178 [144–200] hours respectively. Patients in gr.1 had significantly lower nalbuphine consumption in the first 24 h after surgery and total during hospitalization (0 [0–5] mg versus 15 [10–20] and 20 [15–25] mg in the first 24 h in groups 2 and 3, respectively (p < 0.001). Gr. 1 had lower number of patients with severe pain (10% vs. 47 and 60% in groups 2 and 3, respectively, p < 0.05), lower number of on demand analgesia (0 [0–1] vs. 3 [2–4] and 4 [3, 4] in groups 2 and 3, respectively), better sleep quality (8 [7–9] vs. 6 [5–7] and 4 [3, 4] in groups 2 and 3, respectively, p < 0.001), significantly faster mobilization after surgery – sitting in bed and getting to his feet. MINS was diagnosed significantly more often in gr. 2 and 3 compared with gr. 1 (OR 9 95 CI 1,01–77, p = 0,048 for gr. 2 and OR 11 95 CI 1,2–91, p = 0, 03 for gr. 3). However, none of the patients had symptoms of myocardial ischemia and was not diagnosed with myocardial infarction. There were no difference in the incidence of nosocomial pneumonia and delirium. Conclusion Perioperative PCB in elderly patients with a proximal femur fracture could be an effective analgesia technique, as it decrease the number of patients with severe pain, need for on demand analgesia and opioid consumption. PCB also decrease the incidence of opioid-associated nausea and vomiting, comparing to general anesthesia, and increase the number of patients, who was mobilized in the 1st day (sitting) and 2nd day (getting up) after surgery. PCB may reduce the incidence of MINS, although to assess this outcome more studies are needed. Trial registration Clinicaltrials.gov: NCT04648332, first registration date 1/12/2020.

The Effect of Peripheral Nerve Block on Postoperative Delirium in Older Adults Undergoing Hip Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…A fascia iliaca compartment block and femoral nerve block were performed in seven studies [ 16 , 17 , 18 , 19 , 28 , 29 , 30 ] and five studies [ 31 , 32 , 33 , 34 , 35 ], respectively. The following types of nerve blocks were performed in the remaining studies: lumbosacral plexus block [ 36 , 37 ], lumbar plexus block [ 38 ], a combination of psoas compartment block and sciatic nerve block [ 39 ], femoral and lateral cutaneous block [ 40 ], a combination of fascia iliaca compartment block and sciatic nerve block [ 41 ], and a combination of fascia iliaca compartment block, sacral plexus block, and superior cluneal nerve block [ 42 ]. In six studies, the local anesthetic was continuously administered through a catheter [ 17 , 19 , 31 , 32 , 38 , 39 ].…”

The effects of anesthesia methods and anesthetics on postoperative delirium in the elderly patients: A systematic review and network meta-analysis

“…Two studies were divided into three groups for comparison. Bielka et al (2021) chose to use two different RA_bupi to compare with GA_sevo. And among the study of Shin et al (2020) , the patients were randomly divided into GA_desf, GA_prop, and SA groups.…”

“…Only Al Tmimi et al (2020) and Siripoonyothai and Sindhvananda (2021) included patients from cardiac surgery. All but five studies ( Coburn et al, 2018 ; Mei et al, 2020 ; Bielka et al, 2021 ; Neuman et al, 2021 ; Li et al, 2022 ) did not report or did not use fentanyl-type analgesics during the anesthesia induction or maintenance phases.…”

“…Interestingly, only the study by Gu et al (2021) found a higher rate of early moderate delirium (24 h postoperatively) in the GA group than the NB group, with no significant between and within groups of severe POD. Bielka et al (2021) used bupivacaine for PCB and sciatic nerve block in the aged undergoing hip fracture surgery. Although the results did not show any difference in the incidence of POD compared to SA or GA, the outcomes according to our NMA showed that PCB (SUCRA value = 42.2%) was preferred over other types of anesthesia methods ( Supplementary Figure 8 ).…”

“…(2021) andTang et al (2021) compared multiple nerve blocks (NB) using ropivacaine and propofol-based IA, respectively. Interestingly, only the study byGu et al (2021) found a higher rate of early moderate delirium (24 h postoperatively) in the GA group than the NB group, with no significant between and within groups of severe POD Bielka et al (2021). used bupivacaine for PCB and sciatic nerve block in the aged undergoing hip fracture surgery.…”