• 
• 

Three Part Question

In [elderly patients with hip fracture presenting in the emergency department], does the [use of regional anesthesia using ultrasound guidance] lowers the [risk of delirium]?

Clinical Scenario

A 78 year old women with no cognitive impairment is brought to the ED with a story of an accidental fall from her height followed by right hip pain and inability to walk or bear any weight on her right leg. Initial evaluation followed by plain films denoted a stable right hip fracture. Initial pain management in the ED was limited. You are concern with the overuse of opiates and development of delirium in the ED and you wonder if the use of regional anesthesia using ultrasound guidance could beneficial for this patient in the ED.

Search Strategy

Search performed on November 7th 2016.

MEDLINE using the PubMed interface (1900 – September 2016)

#1 – ‘'delirium'’ // 13,418 articles
#2 – ‘’hip fracture’ // 35,929 articles
#3 – ‘ultrasound'// 505,025 articles
#4 – 'regional anesthesia'//67,421 articles
#5 – ‘femoral block’ // 2,647 articles
#6 – ‘emergency’ // 302,138 articles
#7 – #1 AND #2 AND #3 // 3 articles
#8 – #1 AND #2 AND #3 AND #4 // 1 articles
#9 – #1 AND #2 AND #3 AND #4 AND #5// 1 articles
#9 – #1 AND #2 AND #3 AND #4 AND #5 AND #6// 1 articles
(((((delirium) AND hip fracture) AND ultrasound) AND regional anesthesia) AND femoral block) AND emergency

- After abstract/title review = 1 paper seemed relevant but studied continuous blocks and were performed by surgeons.

In addition, reference lists of relevant papers were checked for potential studies. No new studies were found.

B. The website www.clinicaltrials.gov was searched for ongoing trials on the subject.

1)Improving Pain and Function in Hip Fracture,
Study completed June 2014
Principal Investigator:
R. Sean Morrison, MD, Icahn School of Medicine at Mount Sinai;
Knox Todd, MD, MPH, M.D. Anderson Cancer Center
2)Delirium in Elderly Patients With Trauma of the Hip (DEPTHip), Currently recruiting May 2016,
Principal Investigator:Markus Hollmann, MD, PhD, PhD, Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)
3) ED Ultrasonographic Regional Anesthesia to Prevent Incident Delirium in Hip Fracture Patients (EDU-RAPID),
This study is not recruiting yet. September 2016
Principal Investigator:
Jacques S Lee, MD ; Sunnybrook Health Sciences Centre

C. Embase using the Elsevier interface (1966– September 2016)

#1 – ‘'delirium'/exp OR delirium’ // 24,522 articles
#2 – ‘'hip'/exp OR hip AND ('fracture'/exp OR fracture)’ // 44,680 articles
#3 – ‘ultrasound'/exp OR 'ultrasound’ // 368,381 articles
#4 – 'regional anesthesia'/exp OR 'regional anesthesia' //47,739 article
#5 – ‘femoral AND block’ // 4,057 articles
#6 – ‘emergency’/exp OR ‘emergency’ // 463,400 articles
#7 – #1 AND #2 AND #3 // 11 articles
#8 – #1 AND #2 AND #3 AND #4 // 9 articles
#9 – #1 AND #2 AND #3 AND #4 AND #5// 7 articles
#9 – #1 AND #2 AND #3 AND #4 AND #5 AND #6// 6 articles

After reviewing the articles, 1 relevant paper was found.
In addition, reference lists of relevant papers were checked for potential studies. No new studies were found.

D. No BestBETs or critical appraisals were found on this topic.
E. The Cochrane Library was searched for reviews on the subject.
No reviews were found.

Search Outcome

Altogether 1 paper was found in Medline and 1 in EMBASE, of which 1 was irrelevant or of insufficient quality (consisting mostly of review articles, postoperative outcomes, expert opinions, duplicates or because they were written neither in english nor in french). No papers were found by scanning the references of relevant papers. All relevant papers are summarized in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
M.Y. Woo, J. Bradley, I.G. Stiell, and al. 2014 Ottawa, Canada	Convenient sample (n=100) of of patients more than 16 years old presenting to the ED with a hip fracture and evaluated by trained physician with femoral nerve block (FNB) (n=22). A historical cohort was compared to a prospective FNB cohort .(Jan 2008 -Jul 2011).	Pilot Prospective Paired-case Control study	Total dosage morphine equivalents at 1, 4, and 24 hours (primary)	Mean morphine equivalents were similar at 1 hour [3.2mg (95%CI 2.4-4.1) vs. 4.2 mg (95%CI 0.9-7.5)], 4 hours [5.9mg (95%CI 4.5-7.2) vs. 6.8mg (95%CI 2.4-11.3)], and 24 hours [18.1mg (95%CI 15.1-21.1) vs. 12.9mg (95%CI 2.3-23.5)]	Pilot study Low N of patients
			In-hospital complications	Similar for both cohorts except for UTIs and delirium. Favouring the FNB group. (UTI 46.2% vs. 9.1%, p=0.002; delirium 55.8% vs. 18.2%, p=0.003)
			Complications related to the block (local anesthetic systemic toxicity, nerve or vascular injury, infection)	No complications from the FNB.

Comment(s)

The feasibility of 3:1 femoral block under US guidance is simple and its learning curve is relatively high for trainee physicians1. Numerous studies show relative benefits of femoral nerve block (FNB) in the ED in the elderly population with hip fracture2 on pain management, length of stay an delirium. Setta’s systematic review3 in 2010 on pain management in hip fracture revealed moderate evidence that femoral blocks reduces incidence of delirium and length of stay in hospital. The use of ultrasound guidance in the FNB technique have shown better clinical success than the anatomical approach for pain management4. The extrapolation to clinical outcomes such as reduction of delirium and reduction of opioids use during the preoperative period has yet to be illustrated with the ultrasound guidance. Three prospective randomized-control trials (EDU-RAPID, DEPTHip, Morrison-Mount Sinai) currently ongoing will try to confirm the clinical trend favouring the use of femoral nerve block in the management of delirium in hip fracture in the elderly.

Clinical Bottom Line

This pilot study may show some changes on delirium incidence but is retrospective and with a low number of patients. Three prospective randomized-control trials (EDU-RAPID, DEPTHip, Morrison-Mount Sinai) currently ongoing will try to confirm the clinical trend favouring the use of femoral nerve block in the management of delirium in hip fracture in the elderly. References 1. A brief educational intervention is effective in teaching the femoral nerve block procedure to first-year emergency medicine residents. Akhtar S, Hwang U, Dickman E, et al. Journal of Emergency; 2013 Nov;45(5):726-30. doi: 10.1016/j.jemermed.2013.04.051. Epub 2013 Aug 30. 2. Mangram, Alicia J. and al. Geriatric trauma G-60 falls with hip fractures: A pilot study of acute pain management using femoral nerve fascia iliac blocks, Journal of Trauma and Acute Care Surgery. 79(6):1067-1072, December 2015. 3. Abou-Setta AM, Beaupre LA, Rashiq S, Dryden DM, Hamm MP, Sadowski CA, et al. Comparative Effectiveness of Pain Management Interventions for Hip Fracture: A Systematic Review. Ann Intern Med. 2011;155:234-245. doi: 10.7326/0003-4819-155-4-201108160-00346 4. Ultrasound-guided three-in-one nerve block for femur fractures. Christos SC, Chiampas G, Offman R, Rifenburf, R West; West Journal of Emergency Medicine, 2010 Sep;11(4):310-3. 5. R. Sean Morrison, MD, Icahn School of Medicine at Mount Sinai; Knox Todd, MD, MPH, M.D. Improving Pain and Function in Hip Fracture, Anderson Cancer Center, https://clinicaltrials.gov/ct2/show/NCT00749489?term=delirium+AND+hip+fracture&rank=23 6. Principal Investigator:Markus Hollmann, MD, PhD, PhD. Delirium in Elderly Patients With Trauma of the Hip (DEPTHip),Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA) https://clinicaltrials.gov/ct2/show/NCT02689024?term=delirium+AND+hip+fracture&rank=10 7. Jacques S Lee, MD ; ED Ultrasonographic Regional Anesthesia to Prevent Incident Delirium in Hip Fracture Patients (EDU-RAPID), Sunnybrook Health Sciences Centre https://clinicaltrials.gov/ct2/show/NCT02892968?term=delirium+AND+hip+fracture&rank=2

References

1. M.Y. Woo, J. Bradley, I.G. Stiell, and al. Pilot prospective cohort study for the use of ultrasound guided 3 in 1 femoral nerve blocks in a tertiary care emergency department in patients presenting with a hip fracture