Proximal Femur Fracture
Conditions
Brief summary
This patient population is typically elderly and frail. They are at risk of adverse effects secondary to inadequate pain management such as prolonged admissions and poor functional outcomes. Regional analgesia is preferred due to their opioid-sparing effects and reduction in related adverse effects but The analgesia from these blocks is only moderate and literature suggests that the obturator nerve (ON) is not covered.
Detailed description
The aim of this study is to compare the effect of combined lateral femoral cutaneous nerve block with pericapsular nerve group block versus fascia iliaca block for proximal femur surgery. Fascia iliaca compartment block is a simple technique to manage pain before positioning for spinal anesthesia performance and it constitutes a practical choice for perioperative pain control. A recent anatomical study confirmed the innervation of the anterior hip by these 3 main nerves, but also found that the AON and FN play a greater role in the anterior hip innervation than previously reported The high articular branches from FN and AON are consistently found between the anterior inferior iliac spine (AIIS) and the iliopubic eminence (IPE), whereas the ON is located close to the inferomedial acetabulum. The ultrasound-guided technique for blockade of these articular branches to the hip, the PENG (Pericapsular Nerve Group) block reported significantly reduced pain scores compared with baseline. Roy et al 2019 recommended the use of PENG block together with LFCN block as adjunctive to cover the lateral surgical incision.
Interventions
PROCEDUREFascia iliaca block
A linear probe will be placed in the sagittal plane to the inguinal ligament to obtain an image of bow-tie sign formed by the muscle fascias, a spinal needle will be inserted 1 cm cephalad Using an in-plane approach, the fascia iliaca is penetrated, 30 mL of bupivacaine 0.25% before spinal anesthesia.
PROCEDUREcombined LFCN block with PENG block
With the patient supine, the linear probe is placed parallel to the inguinal ligament. LFCN appear as a hypoechoic oval structure between the tensor fascia lata and Sartorius muscles. The needle is inserted in plane. 5 mL of LA is injected. The PENG block will be performed in the supine position. A curvilinear probe will be placed transversely over the anterior inferior iliac spine and then rotated counterclockwise 45 degrees. the ilio pubic eminence, the iliopsoas muscle and tendon, the femoral artery, and pectineus muscle will be observed. A spinal needle will be inserted in plane to the plane between the psoas tendon and the pubic ramus. 25 mL of bupivacaine 0.25% will be injected
Sponsors
Mansoura University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
SINGLE (Outcomes Assessor)
Masking description
Single-blind study
Eligibility
Sex/Gender
ALL
Age
50 Years to 90 Years
Healthy volunteers
No
Inclusion criteria
* American Society of Anesthesiologists (ASA) physical status I, II and III.
Exclusion criteria
* Patient refusal. * Neuromuscular diseases * Hematological diseases * Bleeding abnormality * Coagulation abnormality. * Psychiatric diseases. * Local skin infection at the site of the block. * Local skin sepsis at the site of the block * Known intolerance to the study drugs. * Body Mass Index \> 40 Kg/m2. * Multiple trauma patients.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Time of performance of Spinal Anesthesia | just before surgery. | Is defined as the time measured from the start of positioning to the completion of the intrathecal bupivacaine injection |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Pain measurement on movement | immediately and 1 hour at PACU, then in the surgical ward at 2,4,6,8,12,18 and 24 h after surgery. | (attempted hip flexion to 15 degrees).: 10-cm visual analog scale (VAS) for pain, where 0 is equal to no pain and 10 indicates the worst possible pain |
| Pain measurement during positioning for spinal anesthesia | Just before surgery | visual analog scale (0-10, 0: no pain, 10: worst pain imaginable) during changing position from supine to sitting one |
| The severity of postoperative pain at rest | immediately and 1 hour at PACU, then in the surgical ward at 2,4,6,8,12,18 and 24 h after surgery. | 10-cm visual analog scale (VAS) for pain, where 0 is equal to no pain and 10 indicates the worst possible pain |
| The severity of postoperative pain on movement | immediately and 1 hour at PACU, then in the surgical ward at 2,4,6,8,12,18 and 24 h after surgery. | (attempted hip flexion to 15 degrees): 10-cm visual analog scale (VAS) for pain, where 0 is equal to no pain and 10 indicates the worst possible pain |
| Time to onset of Sensory blockade | evaluated 15 and 30 min after block administration | cold perception loss in the lateral, anterior and medial part of the thigh (corresponding to lateral femoral cutaneous (LFC), femoral (F) and obturator (O)nerve sensory distributions, respectively) |
| Time to onset of motor block | evaluated 15 and 30 min after block administration | defined as assessment of quadriceps femoris muscle strength by straight leg raise test to 15 degree and classified as follow: +ve =normal power, -ve =motor weakness |
| Duration of sensory block | postoperative 24 hours | blockade is defined as the interval between end of injection and complete end of sensory block (score=2) |
| Duration of motor block | postoperative 24 hours | blockade is defined as the interval between end of injection and complete end of injection and complete recovery of normal motor function (score=0), |
| Pain measurement at rest | immediately and 1 hour at PACU, then in the surgical ward at 2,4,6,8,12,18 and 24 h after surgery. | 10-cm visual analog scale (VAS) for pain, where 0 is equal to no pain and 10 indicates the worst possible pain |
| heart rate | pre-block, 15, 30 min after block, immediately after spinal anesthesia, 5min, 15min then every 30 min till end of surgery | Changes in heart rate |
| Mean arterial blood pressure | pre-block, 15, 30 min after block, immediately after spinal anesthesia, 5min, 15min then every 30 min till end of surgery | Changes in Mean arterial blood pressure |
| Peripheral oxygen saturation | pre-block, 15, 30 min after block, immediately after spinal anesthesia, 5min, 15min then every 30 min till end of surgery | Changes in peripheral oxygen saturation as measured with pulse oximetry |
| Time for first analgesic request | Within 24 hours after surgery | defined as the time period from end of injection to the first time patient requests analgesia postoperatively |
| Total analgesics received | for 24 hrs after surgery | cumulative consumption of opioids during the first postoperative day |
| Pruritis | Within 24 hours after surgery | number of patients with pruritis |
| nausea | Within 24 hours after surgery | number of patients with nausea |
| vomiting | Within 24 hours after surgery | number of patients with vomiting |
| Anesthesiology satisfaction for patient positioning | just before surgery | evaluated as 0=unsatisfactory, 1=satisfactory, 2=good or 3=optimal |
Countries
Egypt
Contacts
Primary ContactMona A Hasheesh, MD
Backup ContactEiad A Ramzy, MD
Outcome results
None listed