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Three Part Question

In [patients with femoral neck fractures] is [fascia iliaca block better than opiates and NSAIDs] in [providing effective pain relief]

Clinical Scenario

A 78 years old female, a 87 years old male, a 64 years old male and a 53 years old female, all had falls and confirmed fracture neck of femur. All had received IV Morphine for pain by the ambulance crew. They received fascia iliaca block (FIB) with 0.25% levobupivacaine adjusted to their estimated weight by the emergency physicians.
Their pain scale varied between moderate to severe. We were expecting drastic improvement in pain within the first 30-60 minutes after instilling the blocks. Instead all had no pain relief even after 1-2 hours and required additional analgesics to reduce the pain in the emergency department.

Search Strategy

Medline/ PubMed and Cochrane Library search-


1. Neck of femur fractures AND Fascia iliaca block AND Opiates AND NSAIDs AND pain relief AND Emergency department: Clinical Trial, Meta-Analysis, Randomized Controlled Trial, Review, Systematic Review, in the last 10 years – 883 results.
2. Levobupivacaine AND Femoral fracture OR Neck of femur fracture AND Emergency department OR Casualty OR Accident and Emergency AND Analgesia OR Pain relief OR Pain management AND Controlled trial OR Meta-analysis OR Reviews, in the last 10 years - 33 results.

Search Outcome

Searched 883 articles, reduced to 21 depending on the relevance and narrowed it to 6. Papers were selected if the study included FNB or FICB, with use of levobupivacaine. Studies which were done in ED were taken as a bonus. Discarded 3 paediatric, 1 case series, 1 duplicate, 3 procedures, 1 review, 6 RCTs studies.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Acharya R et al, 2018 India	60 patients with intra trochanteric fracture of femur. 30 each in two groups. All received ultrasound guided FIB. Group H received 28ml 0.5% Levobupivacaine + 2ml 8mg Dexamethasone. Group L received 28ml 0.5% Levobupivacaine + 1ml 4mg Dexamethasone + 1ml normal saline. The effect of analgesia produced between these groups was compared.	Single centre, double blinded randomised controlled trial. CBEM level 2 downgraded to 4	8mg dexamethasone is better than 4mg dexamethasone in providing longer duration of analgesia when used as an adjuvant with 0.5% levobupivacaine in FIB.	In Group H the duration of analgesia (17.02+/- 0.45 hours) was longer when compared to Group L (14.29 +/- 0.45 Hrs), p = 0.000. In Group H post-op opiate (Tramadol) requirement was less 100mg/ day than 200mg/day in Group L.	Small sample, single centre study. The data sets for onset, duration and peak analgesia after FIB and opiate dosages are not available to interpret.
Groot L et al, 2015 Netherlands	43 patients with hip fractures. All received FICB with 2mg/kg of 0.5% levobupivacaine (maximum of 175mg) and opiate for pain in ED. This study evaluated the safety profile and success rate of FICB.	Single centre prospective non randomised controlled cohort study. CBEM level 3, downgraded to 5.	In a busy ED, with varied level of expertise of ED physicians, FICB is efficient, safe and practical method in controlling pain in hip fractures. 65% , 64% and 72% patients had effective pain relief at 2, 4 and 8 hours respectively after FICB.	After FICB patients had less pain ( p=0.04). An effective reduction of pain was seen after 30 mins in 62% patients (54% along with the use of opioids and 8% without opioids). At 4 hours 82% patients (18% with opioids and 64% without opioids) and at 8 hours 88% patients (16% with opioids and 72% without opioids) had effective pain relief.	Single centre small sample with significant dropout of study subjects. 106 patients (71%) excluded from the initial sample size of 149. Very poor data collection especially pain scores with data missing from the study sample of 43 patients at 2, 4 and 8 hours after FICB. Poor presentation of the data in the tables.
Rowlands M et al, 2018 UK	111 patients with hip fractures, admitted through ED. 55 patients, received in ED an Ultrasound guided FNB ( 0.5ml/kg of 0.25% levobupivacaine prior to X-ray. Once confirmed all patients got 0.2% Ropivacaine at 5ml/hr infusion through a perineural catheter. 56 patients, had titrated IV morphine to achieve pain score of 5/10 or less. The objective was to find out whether there was any decrease in pain on movement and mobility in the post-op period.	Single centre, randomised controlled trial. CBEM level 2 downgraded to level 3.	In patients with fracture neck of femur, providing the FNB in ED and continuing the block with local anaesthetic infusion when compared to the standard systemic analgesia did not improve the post-op mobility and pain of these patients. However, there was good pain relief at rest.	No significant difference between the two care groups. Cumulative dynamic pain score 20 (IQR 15-24) vs 20 (IQR 15-23) p=0.51. Cumulated ambulation score 6 (5-9) vs 7 (5-10), p=0.76. Cumulative pain at rest 5 (0.5-6.5) in standard care and 2 (0-5) in intervention care groups.	Single centre study with a small sample. Analysis of the data provided is not easy to interpret. Data for secondary outcome measures not mentioned.
Sriramka B et al, 2019, 2019 India	60 patients with hip fractures. 30 each in two groups. All had ultrasound guided FIB by the anaesthetist. Group LD received 29.5 ml of 0.25% levobupivacaine + 0.5ml of 50mcg dexmedetomidine while group RD received 29.5ml of 0.25% ropivacaine + 0.5 ml of 50mcg dexmedetomidine in FIB. The duration of analgesia and total analgesic requirement in the next 48 hours were observed and compared.	Single centre, double blinded randomised controlled trial. CBEM level 2 downgraded to level 3.	Duration of analgesia (DOA) increases slightly when 50mcg dexmedetomidine is added to the FIB along with 0.25% levobupivacaine. However, there is not much difference in total analgesic (opioid) requirement (TAR).	In group LD, DOA was longer (955.3 +/- 114.5 mins) than group RD (894.6 +/- 91.3 mins), p= 0.027. The TAR in group LD was 112mg, with IQR (Interquartile range) : 105-122mg and in group RD 115mg with IQR 104-118 mg, p = 0.034.	Single centre study. Small sample. Data obtained is not presented well and hence cannot be interpreted.
Urbanek B et al, 2003 Austria	60 patients with neck of femur fractures. All had 3 in 1 block with the help of nerve stimulator. 20 patients received 0.5% bupivacaine, 20 had 0.5% levobupivacaine and the remaining 20 had 0.25% levobupivacaine in the blocks. The onset time, the quality and duration of the nerve blocks were evaluated by pinprick test on the anterior aspect of the affected thigh at 5,10,20,30,40,50 and 60 mins after the block and in the post-op period. A decrease in sensation by 30% was considered as the onset of analgesia/ anaesthesia, while 0% sensation or complete absence of pin prick considered as full analgesia/ anaesthesia.	Single centre, double blinded randomised controlled trial. CBEM level 2 downgraded to 3.	There is no significant difference in the onset of analgesia and quality of analgesia/anaesthesia when bupivacaine 0.5%, levobupivacaine 0.5% and 0.25% are used for 3 in 1 block. However, with levobupivacaine 0.25% few patients achieved complete blockade and had shorter duration of action. Hence 0.5% levobupivacaine is recommended.	Sensory anaesthesia onset time for bupivacaine 0.5% was 27 mins (20-33), levobupivacaine 0.5% was 24 mins (18-30), levobupivacaine 0.25% was 30 mins (23-36), p=0.49. The quality of blockade was not significantly different among the groups. Complete sensory block 0% sensation was achieved in 16 (80%) of patients in both bupivacaine 0.5% and levobupivacaine 0.5% groups, while only 9 (45%) patients achieved this with 0.25% levobupivacaine, p=0.02. The duration of blockade for 0.5% bupivacaine was 1053 mins (802-1304), 0.5% levobupivacaine was 1001 mins ( 844-1158), and with 0.25% levobupivacaine 707 mins (551-863), p=0.01.	Single centre study, with small sample size. Pain assessment was not done using the pain scores which is much useful in clinical settings. There is no data set available for the onset of pain relief. Hence we won’t know how many of 55% patients who received 0.25% levobupivacaine who did not achieve 100% anaesthesia at 60 minutes also had prolonged onset of action beyond the 30 minutes specified.
Wan H et al, 2020 China	RCTs involving 2478 geriatric patients with hip fractures were studied for the use of FICB, as an analgesic strategy for perioperative pain management. Among them, 15 RCTs used ropivacaine, 06 bupivacaine, 01 lidocaine, 01 mepivacaine and 04 levobupivacaine. Among the RCTs using levobupivacaine all of them were small study groups comprising of total of 320 patients. Among them, 262 patients received levobupivacaine while remaining 58 patients received other analgesics (opiate or paracetamol). Two trials involved the use of 0.5% levobupivacaine (n=207) in a pre-operative setting while the other two were in post-operative setting with one trial using 0.25% levobupivacaine ( n=25, 7.8%) and other using 0.125% levobupivacaine (n=30) as infusion in FICA.	Systemic review of 27 RCTs. Modified RCTs were studied by authors for the quality of FNB, FICB, 3 in 1 block or FICA in peri-operative periods. CBEM level 1 study, downgraded to level 2.	In geriatric patients with hip fractures, during the peri-operative period FICB provides adequate pain relief. It is safe, reliable and is an easy to perform procedure.	On admission to ED/ Ward, FICB provides equal or better pain relief when compared to the conventional analgesics. During and after the surgery, FICB offers superior pain control, to position the patients on the operating table and in the ward. This in turn reduces the need for additional doses of anaesthetics during surgery and analgesics in the ward. Reduction in pain during post-operative period helps in early mobilization and prevents complications.	Sample size of most of the RCTs are small. This review does not involve any comparison studies or discussion about the onset and duration of analgesia provided by different local anaesthetics used for the procedures. Out of 27 RCTs only 4 trials involved the usage of levobupivacaine in FICB, FNB and FICA. All of them had small sample size.

Comment(s)

The current clinical practice in most of the emergency medicine departments in UK and Ireland is to provide efficient pain relief for patients with fracture neck of femur. In the ED this is achieved by a combination of opiates, NSAIDs and most importantly FNB or FIB using local anaesthetics (bupivacaine, ropivacaine or levobupivacaine). The use of ropivacaine and levobupivacaine has become popular due to their reduced cardio and neurotoxicity. RCEM recommends the use of FIB to alleviate the pain in neck of femur fractures in ED. The ED at University hospital in Ayr (NHS Ayrshire and Arran) uses 0.25% levobupivacaine (30-40ml) depending on the estimated weight of the patient, with a maximum of 175mg for FIB. FICB/ FIB with 0.5% levobupivacaine can be provided safely and effectively by any ED physician and ANPs. It provides good pain relief for the first few hours in the EDs and in the ward (Groot L et al, 2015). This also offers much better pain control during the transfer of patients from trolleys to beds and then to operating table. Effective pain control by FICB reduces the additional dosage of anaesthetics during surgery and analgesics in the post–operative period (Wan H et al,2020). With 0.5% levobupivacaine, the onset of sensory anaesthesia was 24 minutes and complete sensory blockade was achieved for 80% patients at 60 minutes (Urbanek B et al, 2003). In another study 65% patients had good pain relief at 2 hours after FICB (Groot L et al, 2015). To increase the duration of action of 0.5% levobupivacaine, 8mg dexamethasone can be added to the block as an adjuvant (Acharya R et al, 2018). When 0.25% levobupivacaine was used for FIB, the onset of anaesthesia was at 30 minutes while only 45% patients achieved complete sensory block at 60 minutes and the duration of blockade was less when compared to that of 0.5% levobupivacaine (Urbanek et al, 2003). The duration of blockage can be increased when 50 mcgm dexmedetomidine is used as an adjuvant. However, the use of dexmedetomidine does not reduce the total opiate dosage (Sriramka B et al, 2019). With FNB, good pain relief at rest can be achieved by adding 0.2% ropivacaine infusion to the 0.25% levobupivacaine block. However, this combination does not provide effective pain relief during post-op mobility and movements (Rowlands M et al, 2018). In the emergency department to manage pain from fracture neck of femur, we need a regional nerve block (FNB or FIB) which is effective (patient should be comfortable with low pain score, requiring less opiate doses and have less pain with change of positions) within the first 60 minutes of providing the block. To this effect there is some evidence to suggest that the usage of 0.5% levobupivacaine in FNB or FICB is substantiated. At present there is very little evidence to suggest that the usage of 0.25% levobupivacaine in FNB or FICB is beneficial for treating patients pain effectively in fracture neck of femur. Abbreviations FIB: Fascia iliaca block; FICB: Fascia iliaca compartment block; FNB: Femoral nerve block; FICA; Fascia iliaca compartment block; RCEM: Royal College of Emergency Medicine.

Clinical Bottom Line

When FIB/ FICB is provided for patients with femoral neck fractures, there is scant evidence to suggest the benifits of using 0.25% levobupivacaine where as there is better evidence to support that using 0.5% levobupivacaine will achieve better pain relief.

References

1. Acharya, R., Sriramka, B. and Panigrahi, S. Comparison of 4 mg dexamethasone versus 8 mg dexamethasone as an adjuvant to levobupivacaine in fascia iliaca block-a prospective study. The Korean Journal of Pain 31(4), p.261
2. Groot, L., Dijksman, L.M., Simons, M.P., Zwartsenburg, M.M.S. and Rebel, J.R. Single Fascia Iliaca Compartment Block is Safe and Effective for Emergency Pain Relief in Hip-fracture Patients. The Western Journal of Emergency Medicine, [online] 16(7), pp.1188–1193
3. Rowlands, M., Walt, G. van de, Bradley, J., Mannings, A., Armstrong, S., Bedforth, N., Moppett, I.K. and Sahota, O. Femoral Nerve Block Intervention in Neck of Femur Fracture (FINOF): a randomised controlled trial. BMJ Open 8(4), p.e019650.
4. Sriramka, B., Panigrahi, S.K., Acharya, R. and Singh, J. Effect of Dexmedetomidine on Levobupivacaine and Ropivacaine in Fascia Iliaca Block for Trochanteric Fractures Treated by Proximal Femoral Nail – A Randomized Trial. Cureus 11(8):e5352
5. Urbanek, B., Duma, A., Kimberger, O., Huber, G., Marhofer, P., Zimpfer, M. and Kapral, S. Onset Time, Quality of Blockade, and Duration of Three-in-One Blocks with Levobupivacaine and Bupivacaine. Anesthesia & Analgesia 2003(97), pp.888–892.
6. Wan, H., Li, S., Ji, W., Yu, B. and Jiang, N. Fascia Iliaca Compartment Block for Perioperative Pain Management of Geriatric Patients with Hip Fractures: A Systematic Review of Randomized Controlled Trials. Pain Research and Management 2020(8503963), pp.1–12.