The effect of early femoral nerve block intervention on preoperative pain management and incidence of postoperative delirium geriatric patients undergoing trochanteric femur fracture surgery: a randomized controlled trial

Abstract

BACKGROUND: Hip fracture is a common clinical problem which causes severe pain in geriatric patients. However, severe pain following fracture may bring on mental disorders and delirium. A neuroinflammatory response with IL-6 and IL-8 has been shown to be associated with the pathophysiology of delirium. In this study, our primary hypothesis is that preoperative femoral nerve block (FNB) intervention in geriatric patients will more effectively attenuate pain following trochanteric femur fracture than the preoperative paracetamol application. Our secondary hypothesis is that interleukin levels (IL-6, IL-8) in cerebrospinal fluid (CSF) will be lower in the femoral nerve block group than the paracetamol group. Our tertiary hypothesis is that the incidence of postoperative delirium will be lower in the femoral nerve block group. METHODS: The patients over 65 years of age with ASA status II-IV and admitted to the Emergency Service for femur fracture were included in this study. Recommendations of the "delirium prevention table" were applied to all of the patients at arrival. In the first group, 15 mg/kg paracetamol was administered intravenously every eight hours. In the second group, femoral nerve blockage was performed, and a catheter was placed. Then, 0.5 mL/kg bupivacaine 0.25% was applied every eight hours. In both groups, pain scores four hours after interventions were recorded. All patients were operated within 48 hours under spinal anesthesia. During spinal anesthesia, 2 mL of CSF samples were taken from all patients for analysis of IL-6 and IL-8 cytokines, and pain scores during positioning were recorded. RESULTS: VAS scores four hours after the first preoperative pain treatment and during the positioning for regional anesthesia were significantly lower in the femoral nerve block group. IL-8 levels are significantly lower in the femoral nerve block group but not in IL-6 levels. The incidence of delirium was less in the femoral nerve block group, but the difference was not statistically significant. CONCLUSION: The femoral nerve block was more effective in preoperative pain management of trochanteric femur fracture and preventing pain during regional anesthesia application. The mean IL-8 level was lower in the femoral nerve block group when compared to the paracetamol group. There is no difference in the postoperative delirium incidence between groups.

Effect on mortality of treatment method and surgery time for hip fracture patients aged over 65 years

“…[27][28][29] Another important situation is the anesthesia type and pain management administered to the patient. [30] Different from the literature, in our study, there was no significant correlation found between the form of anesthesia and mortality. There are publications stating that general anesthesia is linked to more mortality in this patient group; however, it can be said that this was observed more in patients with high risk related to cardiac causes.…”

Ultrasound-guided peripheral nerve blocks for preoperative pain management in hip fractures: a systematic review

“…The trials were published from 2010 to 2021 and the number of randomised participants ranged from 20 to 198. Seven trials investigated the femoral nerve block [ 15 , 16 , 18 , 20 , 21 , 23 , 28 ] and six investigated the fascia iliaca compartment block [ 17 – 19 , 22 , 27 , 29 ]. Of the 12 trials, four sought to blind the patients by using a type of sham block [ 15 , 17 , 19 , 20 ].…”

“…Of the 12 trials, four sought to blind the patients by using a type of sham block [ 15 , 17 , 19 , 20 ]. Eight trials had a single shot US-PNB as intervention [ 15 – 18 , 20 , 23 , 27 , 29 ] whereas four trials administered an initial bolus before placing a catheter for continuous infusion [ 19 , 21 , 22 , 28 ]. One study described testing for block success [ 21 ].…”

“…One study described testing for block success [ 21 ]. One study used dual guidance [ 28 ]. Two trials compared more than one intervention to control; one had two parallel intervention groups (femoral nerve block and fascia iliaca compartment block) compared to one control group [ 18 ]; one trial included peridural anaesthesia, which was of no interest to this review [ 21 ].…”

Management of delirium within intraoperative settings for older adults with hip fracture: a scoping review

“…Inadequate pain control was highlighted as a potential contributor to risk of delirium development (Chuan et al, 2020; Martocchia et al, 2015; Patel et al, 2018; Poeran et al, 2020; Uysal et al, 2020). However, control of pain with morphine in the post‐operative period was found to triple the risk of developing delirium (Smith et al, 2017).…”