The efficacy of fascia iliaca compartment block for pain control after hip fracture: A meta-analysis.
ABSTRACT: BACKGROUND:To assess the effect of fascia iliaca compartment block (FICB) on pain control and morphine consumption in patients with hip fracture. METHODS:We searched databases (PubMed, Embase, Cochrane Library) for eligible randomized controlled trials (RCTs) published prior to September 12, 2018. We only included hip fracture patients who received FICB versus placebo for pain control. Risk ratios (RRs), standard mean differences (SMD) and 95% confidence intervals (CI) were determined. Stata 12.0 was used for the meta-analysis. RESULTS:Eleven trials involving 937 patients underwent hip fracture were retrieved. FICB significantly decreased the pain intensity at 1-8 h (SMD = -1.03, 95% CI [-1.48, -0.58], P = .000), 12 h (SMD = -1.06, 95% CI [-1.36, -0.75], P = .000), 24 h (SMD = -1.14, 95% CI [-1.66, -0.62], P = .000) and 48 h (SMD = -0.96, 95% CI [-1.33, -0.60], P = .000). Moreover, FICB could reduced the total morphine consumption and the occurrence of nausea (P < .05). There was no significant difference between the pain intensity at 72 h (SMD = 0.11, 95% CI [-0.12, 0.34], P = .355). CONCLUSIONS:FICB has a beneficial role in reducing pain intensity and morphine consumption after hip fracture. Moreover, FICB has morphine-sparing effects when compared with a control group. More high-quality RCTs are needed to identify the optimal technique and volume of injectate for FICB.
Project description:PURPOSE:Fascia iliaca compartment block (FICB) provides an analgesic option for total hip arthroplasty (THA) patients. The evidence supporting FICB is still not well established. The purpose of this meta-analysis was to assess FICB for pain control in THA patients. METHODS:PubMed, Embase, Cochrane Library, and Chinese Wanfang database were interrogated from their inceptions to December 15, 2018. We included randomized controlled studies reported as full text, those published as abstracts only, and unpublished data, if available. Data were independently extracted by two reviewers and synthesized using a random-effects model or fixed-effects model according to the heterogeneity. RESULTS:A total of eight RCTs were finally included for meta-analysis. Compared with placebo, FICB could significantly reduce VAS pain scores at 1-8?h (WMD?=?-?0.78, 95% CI [-?1.01, -?0.56], P?=?0.000), 12?h (WMD?=?-?0.69, 95% CI [-?1.22, -?0.16], P?=?0.011), and 24?h (WMD?=?-?0.46, 95% CI [-?0.89, -?0.02], P?=?0.039). Compared with the control group, FICB could significantly decrease the occurrence of nausea and length of hospital stay (P?<?0.05). There was no significant difference between the VAS pain score at 48?h and risk of fall between the FICB and the control groups (P?>?0.05). CONCLUSIONS:FICB could be used to effectively reduce pain intensity up to 24?h, total morphine consumption, and length of hospital stay in THA patients. Optimal strategies of FICB need to be studied in the future.
Project description:OBJECTIVE:To explore patients' experience of receiving pain relief injection for suspected hip fracture from paramedics at the location of the injury. DESIGN:Qualitative interviews within a feasibility trial about an alternative to routine prehospital pain management for patients with suspected hip fracture. SETTING:Patients treated by paramedics in the catchment area of one emergency department in South Wales. PARTICIPANTS:Six patients and one carer of a patient who received fascia iliaca compartment block (FICB). INTERVENTION:FICB administered to patients with suspected hip fracture by trained paramedics. We randomly allocated eligible patients to FICB-a local anaesthetic injection directly into the hip region-or usual care-most commonly morphine-using audited scratch cards. OUTCOMES:Acceptability and experience of receiving FICB, assessed through interview data. We audio-recorded, with participants' consent, and conducted thematic analysis of interview transcripts. The analysis team comprised two researchers, one paramedic and one lay member. RESULTS:Patients had little or no memory of being offered, consenting to or receiving FICB. They recalled the reassuring manner and high quality of care received. They accepted FICB without question. Partial or confused memory characterised experience of subsequent hospital care until surgery. They said their priorities when calling for emergency help were to receive effective care. After hospital treatment, they wanted to regain their health and mobility and resume the quality of life they experienced before their injury. CONCLUSIONS:This study did not raise any concerns about the acceptability of FICB administered at the scene of injury by paramedics to people with suspected hip fracture. It adds to existing evidence about patient and carer experience of on-scene care for people with suspected hip fracture. Further research is needed to assess safety, effectiveness and cost effectiveness of this health technology in a new setting. TRIAL REGISTRATION NUMBER:ISRCTN60065373.
Project description:OBJECTIVES:To explore paramedics' experience of delivering fascia iliaca compartment block (FICB) to patients with suspected hip fracture at the scene of injury. DESIGN:Focus groups within a randomised controlled trial. SETTING:Paramedics based at ambulance stations in the catchment area of one Emergency Department in South Wales, recruited and trained in a feasibility study about an alternative to routine prehospital pain management for patients with suspected hip fracture. PARTICIPANTS:11 paramedics. INTERVENTION:Paramedic-administered FICB to patients with suspected hip fracture. We randomly allocated eligible patients to FICB, a local anaesthetic injection directly into the hip region-or usual care, most commonly morphine - using audited scratch cards. OUTCOMES:Paramedics' experiences of administering FICB gathered through thematic analysis of interview transcripts by two researchers, one paramedic and one lay member. RESULTS:Respondents believed that FICB was a suitable intervention for paramedics to deliver. It aligned with routine practice and was within people's capabilities. They said it took up to 10 minutes longer than usual care to prepare and deliver, in part due to nervousness and unfamiliarity with a new procedure. They praised the training provided but said they were anxious about causing harm by injecting into the wrong location. Confidence increased after one paramedic team successfully treated a patient for local anaesthetic toxicity. Reported challenges related to the emergency context: patients often waited many hours for ambulance arrival; moving patients exacerbated their pain; family and neighbours were present as paramedics administered treatment. CONCLUSIONS:Paramedics are willing and able to administer FICB to patients with suspected hip fracture before ambulance transport to hospital. Feasibility study findings will inform further research. TRIAL REGISTRATION NUMBER:ISRCTN60065373; Pre results.
Project description:Over 300,000 patients in the United States sustain low-trauma fragility hip fractures annually. Multidisciplinary geriatric fracture programs (GFP) including early, multimodal pain management reduce morbidity and mortality. Our overall goal was to determine the effects of a GFP on the emergency department (ED) pain management of geriatric fragility hip fractures.We performed a retrospective study including patients age ?65 years with fragility hip fractures two years before and two years after the implementation of the GFP. Outcomes were time to (any) first analgesic, use of acetaminophen and fascia iliaca compartment block (FICB) in the ED, and amount of opioid medication administered in the first 24 hours. We used permutation tests to evaluate differences in ED pain management following GFP implementation.We studied 131 patients in the pre-GFP period and 177 patients in the post-GFP period. In the post-GFP period, more patients received FICB (6% vs. 60%; difference 54%, 95% confidence interval [CI] 45-63%; p<0.001) and acetaminophen (10% vs. 51%; difference 41%, 95% CI 32-51%; p<0.001) in the ED. Patients in the post-GFP period also had a shorter time to first analgesic (103 vs. 93 minutes; p=0.04) and received fewer morphine equivalents in the first 24 hours (15mg vs. 10mg, p<0.001) than patients in the pre-GFP period.Implementation of a GFP was associated with improved ED pain management for geriatric patients with fragility hip fractures. Future studies should evaluate the effects of these changes in pain management on longer-term outcomes.
Project description:BACKGROUND:Hip fracture causes moderate to severe pain and while fascia iliaca block has been reported to provide analgesic benefit, most previous trials were unblinded, with subsequent high risks of performance, selection and detection biases. In this randomized, control double-blind trial, we tested the hypothesis that a fascia iliaca block provides effective analgesia for patients suffering from hip fracture. METHODS:Thirty ASA I-III hip fracture patients over 70?years old, who received prehospital morphine, were randomized to receive either a fascia iliaca block using 30?ml of bupivacaine 0.5% with epinephrine 1:200,000 or a sham injection with normal saline. The fascia iliaca block was administered by emergency medicine physicians trained to perform an anatomic landmark-based technique. The primary outcome was the comparison between groups of the longitudinal pain score profiles at rest over the first 45?min following the procedure (numeric rating scale, 0-10). Secondary outcomes included the longitudinal pain score profiles on movement and the comparison over 4?h, 8?h, 12?h, and 24?h after the procedure, along with cumulative intravenous morphine consumption at 24?h. RESULTS:At baseline, the fascia iliaca group had a lower mean pain score than the sham injection group, both at rest (difference?=?-?0.9, 95%CI [-?2.4, 0.5]) and on movement (difference?=?-?0.9, 95%CI [-?2.7; 0.9]). These differences remained 45?min after the procedure and the two longitudinal pain score profiles were parallel both for patients at rest and on movement (test of parallelism for patients at rest p?=?0.53 and on movement p?=?0.45). The same parallel change in pain scores over time was observed over 24?h of follow-up (test of parallelism for patients at rest p?=?0.82 and on movement p?=?0.12). These results were confirmed after adjustment for gender, ASA score, and cumulative sums of intravenous morphine received pre-procedure and during-follow-up. In addition, there was no difference between the two groups in total cumulative intravenous morphine consumption at 24?h. CONCLUSION:Fascia iliaca block following anatomic landmarks may not provide supplementary analgesia for patients suffering from hip fracture, when low pain scores are reported after prehospital morphine. Additional larger trials will help reach definitive conclusion. TRIAL REGISTRATION NUMBER:Clinicaltrials.gov - NCT02433548 . The study was registered retrospectively.
Project description:Background:In managing hip fracture, effective pain relief before admission to hospital is difficult without risking side effects. Although emergency departments routinely use fascia iliaca compartment block (FICB), there has been little evaluation of its use by paramedics before hospital admission. We aimed to assess whether a multi-centre randomised trial to evaluate FICB was feasible. Methods:Volunteer paramedics used scratchcards to allocate patients with hip fracture at random between FICB and pain relief as usual. Primary outcomes were mortality and quality of life. We also measured adverse events, costs, final diagnosis, length of stay in hospital, pain scores and quality of care and collected qualitative data about acceptability to patients in interviews, and paramedics in focus groups. We pre-specified criteria for deciding whether to progress to a fully powered trial based on the recruitment of paramedics and patients, delivery of FICB, retrieval of outcome data, safety, acceptability, and diagnostic accuracy of hip fracture. Results:We effectively met all progression criteria: we recruited 19 paramedics who randomly allocated 71 patients between trial arms between 28 June 2016 and 31 July 2017; 57 (31 experimental arm, 26 usual care arm, 80% overall) retrospectively consented to follow-up. Just over half (17/31) of experimental participants received FICB; all others had contraindications, including nine taking anticoagulants. Four of the 31 participants assigned FICB and six of the 26 assigned usual care died within 6 months of hospital admission. Serious adverse events were also similar: 3/35 experimental versus 4/36 in usual care. Paramedics' recognition of hip fracture had sensitivity of 49/64 (77%) with a positive predictive value of 46/57 (81%). We received quality of life questionnaires for 30 of 49 patients (61%) at 1 month and 12 of 17 (71%) at 6 months. Patient satisfaction was similar: experimental mean 3.4 (n = 20) versus 3.5 (n = 13) for usual care. Conclusions:RAPID met all progression criteria within reasonable limits. As equipoise remains, we plan to undertake a fully powered multi-centre trial to test clinical and cost effectiveness of paramedic-administered FICB at the scene of hip fracture. Trial registration:ISRCTN 60065373 sought 5 November 2015.
Project description:Background and Objectives: The effect of supra-inguinal fascia iliaca compartment block (SI-FICB) in hip arthroscopy is not apparent. It is also controversial whether SI-FICB can block the obturator nerve, which may affect postoperative analgesia after hip arthroscopy. We compared analgesic effects before and after the implementation of obturator nerve block into SI-FICB for hip arthroscopy. Materials and Methods: We retrospectively reviewed medical records of 90 consecutive patients who underwent hip arthroscopy from January 2017 to August 2019. Since August 2018, the analgesic protocol was changed from SI-FICB to SI-FICB with obturator nerve block. According to the analgesic regimen, patients were categorized as group N (no blockade), group F (SI-FICB only), and group FO (SI-FICB with obturator nerve block). Primary outcome was the cumulative opioid consumption at 24 hours after surgery. Additionally, cumulative opioid consumption at 6 and 12 hours after surgery, pain score, additional analgesic requests, intraoperative opioid consumption and hemodynamic stability, and postoperative nausea and vomiting were assessed. Results: Among 87 patients, there were 47 patients in group N, 21 in group F, and 19 in group FO. The cumulative opioid (fentanyl) consumption at 24 hours after surgery was significantly lower in the group FO compared with the group N (N: 678.5 (444.0-890.0) µg; FO: 482.8 (305.8-635.0) µg; p = 0.014), whereas the group F did not show a significant difference (F: 636.0 (426.8-803.0) µg). Conclusion: Our findings suggest that implementing obturator nerve block into SI-FICB can reduce postoperative opioid consumption in hip arthroscopy.
Project description:Because the analgesic effect of vitamin C against acute pain remains poorly addressed, this meta-analysis aimed at investigating its effectiveness against acute postoperative pain. A total of seven randomized controlled trials with placebo/normal controls were identified from PubMed, Cochrane Library, Medline, Google Scholar, and Embase databases. Pooled analysis showed a lower pain score (standardized mean difference (SMD) = -0.68, 95% CI: -1.01 to -0.36, p < 0.0001; I2 = 57%) and a lower morphine consumption (weighted mean difference (WMD) = -2.44 mg, 95% CI: -4.03 to -0.86, p = 0.003; I2 = 52%) in the vitamin group than that in the placebo group within postoperative 1-2 h. At postoperative 24 h, a lower pain score (SMD = -0.65, 95% CI: -1.11 to -0.19, p = 0.005; I2 = 81%) and lower morphine consumption (WMD = -6.74 mg, 95% CI: -9.63 to -3.84, p < 0.00001; I2 = 85%) were also noted in the vitamin group. Subgroup analyses demonstrated significant reductions in pain severity and morphine requirement immediately (1-2 h) and 24 h after surgery for patients receiving intravenous vitamin C but not in the oral subgroup. These findings showed significant reductions in pain score and opioid requirement up to postoperative 24 h, respectively, suggesting the effectiveness of perioperative vitamin C use. Further large-scale trials are warranted to elucidate its optimal intravenous dosage and effectiveness against chronic pain in the postoperative pain control setting.
Project description:Glucocorticoids are increasingly used perioperatively, principally to prevent postoperative nausea and vomiting (PONV), and acute postoperative pain following total hip arthroplasty (THA). The authors hypothesized that preoperative intravenous glucocorticoids is associated with less pain scores and PONV without increasing the complications after THA.Four databases (PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science) were searched with the limitations of randomized controlled trials (RCTs). The search cutoff date was set at November 6, 2016. Participants were patients who were prepared for primary THA. Intervention was preoperative intravenous glucocorticoids for postoperative pain control. Outcomes including the visual analog scale (VAS) scores at the postanesthesia care unit (PACU) and at 24 and 48 hours post operation, the occurrence of PONV and total morphine consumption were recorded. We calculated risk ratio (RR) with a 95% confidence interval (CI) for dichotomous outcomes, and the weighted mean difference (WMD) with a 95% CI for continuous outcomes.A total of 6 studies were evaluated, which included 297 patients who underwent hip surgery with intravenous glucocorticoid treatment and control patients who underwent hip surgery without glucocorticoid treatment. Pooled results indicated that intravenous glucocorticoid treatment was associated with a reduction of VAS scores at the PACU (WMD?=?-9.06, 95% CI -12.67 to -5.45, P?=?.000) and total morphine consumption by 15.68?mg (WMD?=?-15.68, 95% CI -24.60 to -6.75, P?=?.001). No significant difference was observed in the VAS scores at 24 and 48 hours between the intravenous glucocorticoid and placebo treatments. Intravenous steroids can decrease the occurrence of PONV (RR?=?0.46, 95% CI 0.26-0.82, P?=?.029).Intravenous glucocorticoid treatment can decrease early pain intensity and PONV after THA. However, the evidence for the use of glucocorticoids is limited by the low number of studies and variation in dosing regimens. Thus, additional high-quality RCTs are needed to identify the optimal drug protocol and determine the safety of intravenous glucocorticoids.
Project description:Surgical or nonsurgical treatment for scaphoid waist fracture with slight or no displacement is still controversial. This study compared the efficacy of the 2 methods through meta-analysis to provide a reference for the choice of clinical treatment options. Two individuals independently searched for relevant RCTs and cohort studies from PubMed (1946-February 2018), Embase (1946-February 2018), and Cochrane library (1997-February 2018). After quality assessment and data extraction, Stata 14 software was used for combining the effect size, testing heterogeneity, and studying bias. GRADEpro was used to rate the level of evidence. Ten RCTs and 4 cohort studies with 765 patients were included. No statistical difference in satisfaction, pain, and Disability of the Arm, Shoulder, and Hand score was found after surgical and nonsurgical treatments. Compared with nonsurgical treatment, surgical treatment shortened the time to union (SMD?=?-5.01, 95% CI: -7.47 to -2.58, P?=?.000), decreased the convalescence (SMD?=?-2.09, 95% CI: -3.08 to -1.11, P?=?.000), and reduced the incidence of nonunion (RR?=?0.47, 95% CI: 0.24-0.90), P?=?.023). Subgroup analyses showed that the percutaneous fixation treatment can shorten the time to union [SMD?=?-1.82, 95%CI (-2.22 to -1.42), P?=?=?.000] and the convalescence (SMD?=?-4.26, 95%CI: -6.16 to -2.35, P?=?=?.054), and open reduction fixation treatment can reduce the incidence of nonunion (RR?=?0.20, 95%CI: 0.06-0.69, P?=?=?.01). For scaphoid waist fractures with slight or no displacement, there was no statistical difference in patient satisfaction, pain, and The Disability of the Arm, Shoulder, and Hand scores between surgical treatment and nonsurgical treatment. Closed surgical treatment can shorten the time to union and convalescence, and open reduction can reduce the incidence of nonunion. On the basis of this conclusion, chief physicians can consider which treatment to use according to the patient's clinical situation and their subjective intention.