Use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Older Adults in the Emergency Department: A Systematic Review

AbstractObjectiveHip fractures are a common source of acute pain amongst the frail elderly. One potential technique to adequately manage pain in this population is the femoral nerve block. The objective of this systematic review was to provide updated evidence for the use of femoral nerve blocks as a pain management technique for older hip fracture patients in the emergency department (ED).Data SourcesSearches of Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were conducted between December 2010 and May 2014. The reference list of a previous systematic review was also searched.Study SelectionWe included randomized control trials examining the use of femoral nerve blocks in the ED among older adults (65 years of age or older) with acute hip fracture.Data ExtractionAmong 93 citations reviewed, seven trials were included. Four studies employed a single femoral nerve block, while three studies employed continuous (catheter-placed) femoral blocks. All but one of the studies were found to have a high risk of bias.Data SynthesisAll studies reported reductions in pain intensity with femoral nerve blocks. All but one study reported decreased rescue analgesia requirements. There were no adverse effects found to be associated with the femoral block procedure; rather, two studies found a decreased risk of adverse events such as respiratory and cardiac complications.ConclusionsFemoral nerve blocks appear to have benefits both in terms of decreasing the pain experienced by older patients, as well as limiting the amount of systemic opioids administered to this population.

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15. Barriers to the use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Frail Elders

Inquiry@Queen's Undergraduate Research Conference Proceedings ◽

10.24908/iqurcp.10113 ◽

2018 ◽

Author(s):

Madison Riddell

Keyword(s):

Older Adults ◽

Hip Fracture ◽

Femoral Nerve Block ◽

Femoral Nerve ◽

Common Source ◽

Randomized Control Trials ◽

Nerve Blocks ◽

Rescue Analgesia ◽

Knowledge Translation Strategies ◽

Randomized Control

Background: Hip fractures are a common source of pain and related morbidity among the frail elderly. One technique that has been shown to adequately manage pain in this population is the femoral nerve block. However, it is not currently employed routinely in Alberta emergency departments. Objective: The first objective was to systematically review the recent literature around the use of femoral nerve blocks. The second objective was to survey physicians about the potential barriers to routinely performing femoral nerve blocks in the emergency department. Materials and Methods: Searches of Medline, EMBASE and the Cochrane Trials database were conducted between 2010 and 2014 to identify randomized control trials examining the use of femoral nerve blocks in the ED to manage acute hip fracture pain among older adults (65 years of age and greater). The results of the systematic review were used to inform the development of the barrier survey. The survey was distributed to physician members of the Alberta Emergency and Bone & Joint Strategic Clinical Networks. Results: Seven randomized control trials were included in the review. Four studies employed a single femoral block, while three employed continuous (catheter placed) femoral blocks. All of the studies reported statistically significant reductions in pain. All but one study reported that patients treated with femoral nerve blocks consumed significantly less rescue analgesia. Finally, there were no significant adverse effects reported with the femoral block procedure. Surveys are still being collected and evaluated. Conclusions: Femoral nerve blocks appear to have benefits both in terms of decreasing pain and limiting the amount of systemic opioids administered to frail older adults experiencing a hip fracture. The results of this review and the barriers survey will help inform the development of knowledge translation strategies to increase the routine use of femoral nerve blocks.

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Analgesia and anaesthesia

Oxford Handbook of Emergency Medicine ◽

10.1093/med/9780198784197.003.0007 ◽

2020 ◽

pp. 281-327

Author(s):

Jonathan P. Wyatt ◽

Robert G. Taylor ◽

Kerstin de Wit ◽

Emily J. Hotton ◽

Robin J. Illingworth ◽

...

Keyword(s):

Emergency Department ◽

Nerve Block ◽

Local Anaesthetic ◽

Local Anaesthesia ◽

Femoral Nerve Block ◽

Rapid Sequence Induction ◽

Femoral Nerve ◽

General Anaesthetic ◽

Intravenous Sedation ◽

Nerve Blocks

This chapter in the Oxford Handbook of Emergency Medicine investigates analgesia and anaesthesia in the emergency department (ED). It looks at options for relieving pain, such as the analgesics aspirin, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), morphine and other opioids, Entonox®, and ketamine, and explores analgesia for trauma and other specific situations. It discusses local anaesthesia (LA) and local anaesthetic toxicity, including use of adrenaline (epinephrine) and general principles of local anaesthesia. It explores blocks such as Bier’s block, local anaesthetic nerve blocks, intercostal nerve block, digital nerve block, median and ulnar nerve blocks, radial nerve block at the wrist, dental anaesthesia, nerve blocks of the forehead and ear, fascia iliaca compartment block, femoral nerve block, and nerve blocks at the ankle. It examines sedation, including drugs for intravenous sedation and sedation in children, and discusses general anaesthesia in the emergency department, emergency anaesthesia and rapid sequence induction, difficult intubation, and general anaesthetic drugs.

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MP024: Ultrasound-guided femoral nerve block versus fascia iliaca block for hip fractures in the emergency department: a randomized pilot study

CJEM ◽

10.1017/cem.2016.165 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S74-S74

Author(s):

J. Chenkin ◽

J.S. Lee ◽

T. Bhandari ◽

R. Simard

Keyword(s):

Emergency Department ◽

Pilot Study ◽

Nerve Block ◽

Hip Fractures ◽

Femoral Nerve Block ◽

Femoral Nerve ◽

Comfort Level ◽

Ultrasound Guided ◽

Nerve Blocks ◽

Pain Scores

Introduction: Regional anesthesia has been shown to be an effective pain control strategy for patients presenting with hip fractures in the emergency department. There are two common methods for performing this block: the femoral nerve block (FNB) and the fascia iliaca compartment block (FICB). The objective of this pilot study is to determine whether one of these two ultrasound-guided block techniques provides superior analgesia to emergency department patients with hip fractures. Methods: Emergency physicians at a single institution were randomized to the FNB or FICB training groups. Participants completed a 2-hour practical workshop covering the technique, followed by a questionnaire to assess their comfort with the block. They were asked to perform their assigned nerve block on any patient in the ED presenting with a hip or femur fracture. Physician comfort level and patient pain scores using a visual analog scale (VAS) were recorded before and after the nerve block were recorded. Comparisons were performed using Student’s t-test and Fisher’s exact test. Results: A total of 20 physicians were enrolled in the study, 10 in the FNB group and 10 in the FICB group. There were no significant baseline differences between the groups with respect to ultrasound or nerve block experience. Following the training, 100% of participants in both the FNB group and FICB group felt comfortable performing the block. Nerve blocks were performed in 30/51 (58.8%) of eligible patients in the FNB group and 6/11 (54.5%) in the FICB group (p=1.0). On the 10-point VAS, pain scores decreased by a mean of 4.9 (SD 3.5) in the FNB group and 8.3 (SD 2.4) in the FICB group (p=0.056). In practice, physicians felt comfortable performing the FNB in 52.8% of cases, and the FICB in 85.7% of cases (p=0.21). Mean time to completion of the blocks was similar between the two groups (19 vs 18 mins, p=0.83). Conclusion: In this pilot study, we found a non-significant trend towards improved analgesia and higher physician comfort with the ultrasound-guided FICB compared with the FNB in patients with hip fractures. We found no differences in time to performing the blocks. These results require confirmation with a larger sample size.

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LO58: Risk factors associated with acute in-hospital delirium for patients diagnosed with a hip fracture in the emergency department

CJEM ◽

10.1017/cem.2017.120 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S47-S48

Author(s):

V. Brienza ◽

C. Thompson ◽

A. Sandre ◽

S.L. McLeod ◽

S. Caine ◽

...

Keyword(s):

Risk Factors ◽

Emergency Department ◽

Hip Fracture ◽

Femoral Nerve Block ◽

Opioid Analgesic ◽

Femoral Nerve ◽

Primary Objective ◽

Hospital Length Of Stay ◽

Multivariable Logistic Regression Analysis ◽

Nerve Blocks

Introduction: Hip fractures affect over 35,000 Canadians each year. Delirium, or acute confusion, occurs in up to 62% of patients following a hip fracture. Delirium substantially increases hospital length of stay and doubles the risk of nursing home admissions and death. The primary objective of this study was to identify risk factors independently associated with acute in-hospital delirium within 72 hours of emergency department (ED) arrival for patients diagnosed with a hip fracture. Methods: This was a retrospective chart review of patients aged 65 years and older presenting to one of two academic EDs with a discharge diagnosis of hip fracture from January 1st 2014 to December 31st 2015. Multivariable logistic regression analysis was used to determine variables independently associated with the development of acute in-hospital delirium within 72 hours of ED arrival. Results: Of the 668 included patients, mean (SD) age was 84.1 (8.0) years and 501 (75%) were female. 521 (78.0%) patients received an opioid analgesic and/or femoral nerve block in the ED. The most common analgesics used in the ED were intravenous (IV) morphine (35.8%), IV hydromorphone (35.2%), or dual therapy with both IV hydromorphone and IV morphine (2.2%). Femoral nerve blocks were initiated for 36 (5.4%) patients and successfully completed in 35 (5.2%) patients in the ED. 181 (27.1%) patients developed delirium within 72 hours of ED arrival. History of neurodegenerative disease or dementia (OR: 5.7, 95% CI: 3.9, 8.4), age >75 (OR: 2.8, 95% CI: 1.4, 5.6) and absence of analgesia in the ED (OR: 2.1, 95% CI: 1.3, 3.2) were independently associated with acute in-hospital delirium. Conclusion: The development of in-hospital delirium is common in patients diagnosed with a hip fracture. We have identified modifiable and non-modifiable risk factors independently associated with acute in-hospital delirium, which can be identified in the ED. Clinicians should be aware of these risk factors in order to implement strategies directed at reducing the development of acute delirium. Additionally, further research is needed in order to understand the relationship between analgesia delivered in the ED and the development of delirium for patients diagnosed with a hip fracture.

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Pre‐operative femoral nerve block for hip fracture—A systematic review with meta‐analysis

Acta Anaesthesiologica Scandinavica ◽

10.1111/aas.13491 ◽

2019 ◽

Vol 64 (1) ◽

pp. 23-33 ◽

Cited By ~ 5

Author(s):

C. Skjold ◽

A. M. Møller ◽

K. Wildgaard

Keyword(s):

Systematic Review ◽

Hip Fracture ◽

Nerve Block ◽

Femoral Nerve Block ◽

Meta Analysis ◽

Femoral Nerve

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Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review

CJEM ◽

10.1017/cem.2015.75 ◽

2015 ◽

Vol 18 (1) ◽

pp. 37-47 ◽

Cited By ~ 25

Author(s):

Brandon Ritcey ◽

Paul Pageau ◽

Michael Y. Woo ◽

Jeffrey J. Perry

Keyword(s):

Systematic Review ◽

Pain Management ◽

Femoral Neck ◽

Nerve Block ◽

Femoral Nerve Block ◽

Femoral Nerve ◽

Femoral Neck Fractures ◽

Controlled Trials ◽

Nerve Blocks ◽

Randomized Controlled

AbstractObjectivesHip and femoral neck fractures are common in elderly patients, who are at an increased risk of complications if their pain is suboptimally managed. This systematic review seeks to determine if regional nerve blocks reduce pain, reduce the need for parenteral opiates, and reduce complications, compared to standard pain management with opiates, acetaminophen, or NSAIDs.Data sourcesSystematic review of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials found 401 articles, of which nine were selected for inclusion.Study selectionRandomized controlled trials including adult patients with a hip or femoral neck fracture (Population) who had a 3-in-1 femoral nerve block, traditional femoral nerve block, or fascia iliaca compartment block performed preoperatively (Intervention). Comparison must have been made with standard pain management with opiates, acetaminophen, or NSAIDs (Comparison) and outcomes must have included pain score reduction (Outcome).Data synthesisEight out of nine studies concluded pain scores were improved with the regional nerve block compared to standard pain management. A significant reduction in parenteral opiate use was seen in five out of six studies. No patients suffered life-threatening complications related to the nerve block; however, more minor complications were under-reported. Most of the studies were at a moderate to high risk of bias.ConclusionsRegional nerve blocks for hip and femoral neck fractures have a benefit in reducing pain and the need for IV opiates. The use of these blocks can be recommended for these patients. Further high-quality randomized controlled trials are required.

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Comparison of patient and surgeon satisfaction in patients undergoing knee arthroscopy with peripheral nerve block versus spinal anesthesia

Journal of Clinical and Investigative Surgery ◽

10.25083/2559.5555/6.2.10 ◽

2021 ◽

Vol 6 (2) ◽

pp. 148-152

Author(s):

Seray Turkmen ◽

◽

Mehmet Mutlu

Keyword(s):

Peripheral Nerve ◽

Spinal Anesthesia ◽

Nerve Block ◽

Knee Arthroscopy ◽

Femoral Nerve Block ◽

Femoral Nerve ◽

Rescue Analgesia ◽

Significant Difference ◽

Duration Of Surgery ◽

Surgeon Satisfaction

Objective. This study aims to compare two different methods of regional anesthesia applied for knee arthroscopy in terms of patient and surgeon satisfaction. Materials and Methods. Eighty patients who underwent knee arthroscopy either with spinal anesthesia (SA) or unilateral sciatic and femoral nerve block (SFNB) were included in the study. A nurse conducted a blind study questionnaire to assess the surgeon and patient satisfaction from anesthesia performed at the end of the surgery. Pain score, demographical data, duration of surgery, motor and sensory block duration, time of first rescue analgesia were recorded and analyzed statistically. Results. A statistically significant difference was found between the patient (p = 0.001; p <0.01) and surgeon (p = 0.022; p <0.05) satisfaction rates, these being lower in the group with SFNB comparable to patients with spinal anesthesia. There was a statistically significant difference between the first analgesic requirements of the patients according to the groups (p = 0.001; p <0.01). The first analgesic requirement of the patients who received SFNB was later than in the case of patients who received spinal anesthesia. Conclusions. Patient and surgeon satisfaction with SA was significantly higher than SFNB. The peripheral nerve blocks are inadequate for patient and surgeon satisfaction for knee arthroscopy compared to SA.

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