Transcript CAT FICB door SEH (io)

Regional analgesia versus systemic
analgesia for femoral fractures in the ED
Leonieke Groot, junior resident
4th Dutch North Sea Emergency Medicine Conference
Introduction:

Femoral fracture: high incidence 1:1000 (WFG 200/jr)

Traditional treatment: systemic opioids

Large potential for side effects: nausea, dizziness, urine retention,
hypotension, respiratory depression, decreased mental state, delerium

Untreated or undertreated pain can increase delerium as well
Marcantonio et al. Reducing delerium after hip fracture: a RCT. J Am Geriatr Soc 49:516-522, 2001
Morrison et al. Relationship between pain and opioid analgetics on the development of delerium following hip
fracture. J Gerontol Med Sci 2003, Vol 58, No1, 76-81
PICO:
•
P = patiënts with femoral fracture in the ED

I = regional block (fascia iliaca compartment block)
performed by Emergency Physicians or junior residents

C = systemic (traditional) analgesia with opioids

O = adequate analgesia and adverse effects/events
Fascia Iliaca Compartment Block:
•
Fast and consistent blockade
•
Simple and easy to learn and use
•
Distant from nerves and blood vessels
•
Without ultrasound guidance or nerve stimulator
Capdevila et al. Comparison of the tree-in-one and fascia iliaca compartment blocks in adults: clinical and
radiological analysis. Anesth Analg 1998;86:1039-44.
Dalens et al. Comparison of the fascia iliaca block with the 3-in-1 block in children. Anesth Analg 1989;
69:705-13.
Search strategie:
•
PubMed search:
Femoral Fractures"[Mesh] AND ("Nerve Block"[Mesh] OR "fascia
iliaca compartment block"[All Fields]) AND ("Pain"[Mesh] OR
"Analgesics, Opioid"[Mesh] OR "Morbidity"[Mesh] OR
"complications "[Subheading] OR "adverse effects "[Subheading])
AND "humans"[MeSH Terms] AND English[lang]
52 articles; eight relevant; three best and most relevant articles.
Related articles: two relevant additional articles
Search strategy:
•
Cochrane Library: one review which could not specifically
answer our question
•
EMBASE: no additional articles found
•
BestBET’s: two relevant BET’s, did not specifically look at
Emergency Physicians or junior residents performing this block
Conclusion:
•
For the acute management of pain in patients with femoral
fractures, FICB is rapidly effective and easily learned and
performed by (junior) Emergency Department staff without
reported adverse effects.
•
FICB has the potential to reduce the reliance to opioids and their
side effects, esspecially in a fragile group of patients.
•
Level of recommendation: B.
Comments:
•
Most of the studies were relatively small and not fully blinded
Clinical bottom line:
•
In patients with femoral fracture, FICB can be safely performed
by Emergency Physicians and junior residents in the ED
•
FICB provides better pain relief and gives less adverse events
than systemic opioids.
Literature:
•
Capdevila X, Biboulet Ph, Bouregba M, et al. Comparison of the tree-in-one and fascia iliaca
compartment blocks in adults: clinical and radiological analysis. Anesth Analg 1998;86:103944
•
Chesters A, Elkhodair S, Mortazavi, et al. Fascia iliaca compartment block in the emergency
department. Emerg Med J 2009;26(Suppl I):A1-A12.
•
Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca block with the 3-in-1 block
in children. Anesth Analg 1989; 69:705-13.
•
Elkhodair S. Fascia iliaca compartiment block for control of hip/femur fracture pain in adult
patients. BestBETs last modified 14th november 2008.
•
Foss NB, Kristensen BB, Bundgaard M, et al. Fascia iliaca compartment blockade for
acute pain control in hip fracture patients: a randomized, placebo-controlled trial.
Anaesthesiology 2007; 106:773-8.
•
Haddad FS, Williams RL. Femoral nerve block in extracapsular femoral neck fractures. J Bone
Joint Surg Br 1995;77(6):922-3.
•
Hauritz RW, Gerlif C, Ronholm E. Fascia iliaca block performed by emergency
department physician trainees in hip fractures. Ugeskr Laeger 2009 Feb 9;171(7):515-8.
Literatuur (2)
•
Hogh A, Dremstrup L, Skov Jensen S, Lindholt J. Fascia iliaca compartment block
performed by junior registrars as a supplement for pre-operative analgesia for patients
with hip fracture. Strat Traum Limb Recon (2008) 3:65-70.
•
Marcantonio ER, Flacker JMF, Wright RS, et al. Reducing delerium after hip fracture: a
randomised clinical trial. J Am Geriatr Soc 49:516-522, 2001.
•
Martin B. Regional nerve block in fractured neck of femur. BestBETs.
•
Monzon DG, Iserson KV, Vazquez JA. Single Fascia iliaca compartment block for posthip fracture pain relief. The J of Emergency Medicine, Vol 32, No 3, pp:257-262, 2007.
•
Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgetics
on the development of delerium following hip fracture. J Gerontol Med Sci 2003, Vol 58, No1,
76-81.
•
Wathen JE, Gao D, Merritt G, Georgopoulos G, Battan FK. A randomized controlled trial
comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic
for femur fractures in a pediatric emergency department. Annals if Emergency
Medicine, Volume 50, no.2:August 2007.
•
Yun MJ, Kim MK, Han MK. Anagesia before a spinal block for femoral neck fracture: fascia
iliaca compartiment block. Acta Anaesthesiol Scand 2009; 53:1282-1287.
Thank you for listening
Are there any questions?