Ultrasound-Guided Femoral Nerve Block in Geriatric Patients with Hip Fracture in the Emergency Department

Abstract

Background and Objectives: Systemic analgesics, including opioids, are commonly used for acute pain control in traumatic hip fracture patients in the emergency department (ED). However, their use is associated with high rates of adverse reactions in the geriatric population. As such, the aim of this study was to investigate the impact of lidocaine-based single-shot ultrasound-guided femoral nerve block (USFNB) on the standard care for acute pain management in geriatric patients with traumatic hip fracture in the ED. Methods: This retrospective, single-center, observational study included adult patients aged ≥60 years presenting with acute traumatic hip fracture in the ED between 1 January 2017 and 31 December 2020. The primary outcome measure was the difference in the amount of opioid use, in terms of morphine milligram equivalents (MME), between lidocaine-based single-shot USFNB and standard care groups. The obtained data were evaluated through a time-to-event analysis (time to meaningful pain relief), a time course analysis, and a multivariable analysis. Results: Overall, 607 adult patients (USFNB group, 66; standard care group, 541) were included in the study. The patients in the USFNB group required 80% less MME than those in the standard care group (0.52 ± 1.47 vs. 2.57 ± 2.53, p < 0.001). The multivariable Cox proportional hazards regression models showed that patients who received USFNB achieved meaningful pain relief 2.37-fold faster (hazard ratio (HR) = 2.37, 95% confidence intervals (CI) = 1.73–3.24, p < 0.001). Conclusions: In geriatric patients with hip fractures, a lidocaine-based single-shot USFNB can significantly reduce opioid consumption and provide more rapid and effective pain reduction.

Effect of early ultrasound-guided femoral nerve block on preoperative opioid consumption in emergency patients with hip fracture: a randomized trial

“…Although previous reviews have already supported the use of ultrasound-guided preoperative nerve blocks, suggesting reduced pain, less need for opioids and a reduced risk of adverse events compared to systemic analgesia, there was no trial considered to have low risk of bias [24,25,35]. Above all, few have examined the effects of a single ultrasound-guided FNB when performed by an emergency physician [18,[26][27][28][29]. The 60% opioid reduction in the first 48h of care is similar to that of a trial evaluating the 24-hours effects of FNB performed blindly (i.e.…”

“…The median of preoperative opioid consumption was reduced by 60% in the ultrasound-guided FNB group compared to standard group (6 MME [3][4][5][6][7][8][9] vs. 15 MME [11][12][13][14][15][16][17][18]), with a consumption difference of 9 MME (95% CI: 3-14, P < 0.001). Medians of preoperative opioid consumption during the first 6 h after the triage time and from 6 h to the time of surgery are presented in Table 2.…”

“…In EDs, the use of FNB has been restricted because of both shortage of skilled physicians and equipment [14,15]. Since ultrasound guidance became the gold standard for regional anesthesia [16], emergency physicians' skill and comfort with ultrasound bedside techniques have increased to perform FNBs [17][18][19]. Recent reviews have coined that ultrasound-guided FNB was more effective and safer than blocks performed with nerve stimulator or blindly.…”

“…Observational studies suggested that ultrasound-guided FNB was a promising strategy for decreasing pain during the many hours spent in the ED [18,[21][22][23][24]. The level of evidence is low, however, due to the few randomized trials conducted, the high degree of statistical heterogeneity, and some degree of clinical heterogeneity both in the timing of implementation of ultrasound-guided FNB and in the assessment of its effects [24,25].…”

Trends of Regional Anesthesia Studies in Emergency Medicine: An Observational Study of Published Articles

“…3,4 Numerous studies have demonstrated that nerve blocks can lower pain scores more than systemic analgesia. 5,6 Using RA can also reduce the incidence of delirium, length of hospital stay, and mortality rate, even when administered in the emergency department (ED) or prehospital setting. 7,8 In EM, indications for RA are diverse, including shoulder reduction, acute pain management in traumatic fracture, headache, herpes zoster, acute pancreatitis, and paraphimosis reduction.…”