Article: Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial
Adequate analgesia in patients with acute hip fractures often presents a challenge for ED providers and there is evidence that increased pain is associated with worse outcomes, suboptimal rehabilitation and recovery. Ultrasound guided femoral nerve blocks is an adjunct to to standard oral and IV analgesics that can improve patient pain in the ED, but is a procedure rarely done despite providers having the necessary skill set.
This study looked at the efficacy of US guided femoral nerve blocks (performed by ED providers at time of admission) followed by a continuous fascia iliaca block (performed by anesthesiologists within 24 hrs) at the treatment of hip fracture pain. 160 patients were included in the study, ~80 in each arm. The control group received standard IV and oral analgesics at the discretion of the treating provider while the study group received the standard analgesics in addition to the femoral nerve block. Primary outcomes were pain at the 1 hr, 2 hr interval, POD3, pain w/ movement, distance walked, and mobility at 6 weeks.
Results showed that patients in the study group had significantly decreased pain at 1 hr and 2 hrs s/p FNB (3.5 vs 5.3), on POD3 (2.9 vs 3.8), decreased pain with transfers, walking, and longer distance walked on POD3 (170ft vs 100ft in 2 mins). A secondary outcome of the study was that there was a 33% reduction in parenteral morphine equivalents administered as well as decreased side effects attributed to opiate usage.
The study suggests that FNBs performed in the ED followed by cFIB results in better analgesia and increased mobility than standard IV/PO analgesics alone. It is suggested that this is incorporated in routine practice for the management of pain in acute hip fractures.
Limitations:
1) Possible placebo effect: It is difficult to quantify how much of the improved analgesia can be attributed to the placebo effect as the control arm of the study did not receive a sham injection. This however would be unethical and impractical for a study.
2) Excluded patients: 1088/1250 of patients screened were not part of the study. This challenges the generalizability of the findings.
3) Mode of data collection: One of the key outcomes – mobility at 6 weeks – was assessed by phone. This may be an inaccurate modality given that 29% of those patients were considered lost to follow up.
Despite these limitations, there is a strong argument presented that patients with acute hip fractures would have more adequate analgesia and improved recovery if a femoral nerve block is performed in the ED. Furthermore, this is a skill that ED providers should be competent and proficient at, and incorporation of this procedure in the routine care of acute hip fractures would be beneficial for patients and reduce the need for frequent re-dosing of IV analgesics.
This article was reviewed, presented and summarized by Mohamed G. Mohamed, MD – PGY-2.