SOFT Block Versus Spinal Anesthesia in Patientsusing Ilizarov External Fixator

January 22, 2019 updated by: Hoda Shokri, Ain Shams University

SOFT Block Versus Spinal Anesthesia in Patients Undergoing Surgery for Fixation of Open Tibial Fractures Using Ilizarov External Fixator

Peripheral nerve block is an ideal choice for lower limb surgery because of the peripheral site of the surgical procedure and the ability to block pain pathways at multiple levels. On the contrary to other anesthetic techniques, as spinal or general anesthesia, properly performed peripheral nerve blocks bypass adverse events as hemodynamic instability and respiratory complications, properly treat post-operative pain leading to early hospital discharge. Additional advantages of peripheral nerve blocks are that they can be used in patients receiving anti-coagulants or lumbosacral disease in addition to avoidance of airway instrumentation.

Recently, there has been a significant interest in regional anesthesia and peripheral nerve blockade. This is facilitated by a significant advance of the research in this field and availability of better equipment facilitating regional anesthesia.The aim of this study was to assess the efficacy and safety of SOFT block (sciatic-obturator-femoral nerve block technique) in comparison with spinal anesthesia in patients undergoing surgery for fixation of open tibial fractures using Ilizarov external fixator.

Study Overview

Status

Completed

Conditions

Detailed Description

After the approval of medical ethical committee of Ain Shams University, this prospective parallel group double blinded study will be conducted over 60 patients between the age of 35-57 years old, ASA physical status I and II, scheduled for fixation of open tibial fractures using iIlizarov external fixator. at Ain Shams University hospitals in 2018-2019, After written informed consent is obtained.

Refusal to participate, inability to communicate with the investigators or hospital staff, obesity (body mass index>40 kg/m2), patients undergoing bilateral surgery, patients with coagulopathies ,renal insufficiency (creatinine>1.5 mg/dL), American Society of Anesthesia (ASA) III-IV, patients with any contraindication to regional anesthesia , patients with unstable vital data and patients with head or chest trauma will be excluded.

Preanesthetic check will be done at night of surgery. After an intravenous (IV) cannula will be secured , and midazolam 0.05 mg/kg i.v. will be given to all patients before transfer to the operating room where standard monitoring devices as ECG,Non invasive blood pressure and pulse oximetry will be placed. Then, patients will be randomly allocated by sealed envelope technique to receive either spinal anesthesia or SOFT block. In spinal anesthesia group, patients will receive spinal anesthesia with hyperbaric bupivacaine 0.5% (7.5-10mg). This will be administered via a 25-G spinal needle at L4-L5 or L3-L4 with the patient in the sitting position under complete aseptic conditions.

In SOFT group, patients will receive SOFT block where patients will be positioned in supine position,under aseptic conditions, a linear US probe will be placed on the inguinal crease to show the femoral nerve and vessels. Using an in-plane technique, a 12-cm stimulating block needle will be introduced medial to the femoral vein and advanced 1-3 cm below and parallel to the skin. Then, It will be redirected toward the fibres of the femoral nerve, where 15 mL of bupivacaine 0.25% will be injected. To block the obturator nerve, the probe will be shifted medially, superior to the needle, and directed cranially to identify the pectineus muscle . The needle will be then withdrawn to the subcutaneous tissue and redirected using an out-of-plane technique toward the deep surface of the pectineus, where 10 mL of bupivacaine 0.25%will be injected.[4 ] To locate the sciatic nerve, we will use the curvilinear probe, directed it inferior to the needle, and tilted the probe to get the clearest image of the sciatic nerve.The needle will be inserted then withdrawn subcutaneously and directed by an in-plane technique toward the sciatic nerve deep to the inferior border of the quadratus femoris muscle. Then 20 mL of bupivacaine 0.25% will be injected after needle elicited muscle twitches using 1 mA current.

Sensory level will be evaluated by loss of pinprick sensation (20-gauge hypodermic needle).

Haemodynamic variables will be recorded every 5 min after block performance until the end of surgery. Hypotension will be defined as a decrease in systolic arterial blood pressure by 30% or more from baseline values, and it will be initially treated with 200 ml IV infusion of Ringer's lactate solution; if this proved to be ineffective, an IV bolus of phenylephrine (40-50 mcg) will be given. Bradycardia is defined as heart rate decrease below 45 bpm, and it was treated with 0.5 mg IV atropine.

Sensory block(loss of pinprick sensation at T12 in the Spinal group, or in the femoral, obturator and sciatic nerves distribution in the SOFT group). The quality of the block will be judged according to the need for supplementary IV analgesics and sedation: adequate nerve block = neither sedation nor analgesics required to complete surgery; inadequate nerve block = need for rescue dose of analgesic (100 mg IV bolus of ketamine) or sedation (3mg IV midazolam) will be required to complete surgery; failed nerve block so general anesthesia will be required to complete surgery.

After completion of surgery, patients will be transferred to the post-anesthesia care unit (PACU). Intravenous pethidine (50 mg) will be given as rescue analgesic as needed. Primary endpoint is the time from the end of local anaesthetic injection to complete resolution of sensory block. The secondary endpoints include patient satisfaction, (on a numerical rating scale), the adverse events as back pain, postural -puncture headache , vomiting, adverse events of systemic toxicity from local anesthetic as seizures and cardiovascular collapse, persistent parasthesia observed within 48 hours after the block and failure rate of the block will be recorded.

In case of failure of the block or incidence of seizures resulting from local anesthetic toxicity , we will convert to general anesthesia.

In case of cardiovascular collapse, support the patient with intravenous fluids and vasopressors as required so in these cases patients will be excluded from the study.

Study Type

Interventional

Enrollment (Actual)

107

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

      • Cairo, Egypt, 11566
        • Ain Shams University

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

35 years to 57 years (Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • 35 to 57 years old
  • ASA I,II
  • BMI<30
  • fixation of open tibial fractures using Ilizarov external fixator -

Exclusion Criteria:

  • Refusal to participate,
  • Inability to communicate with the investigators or hospital staff,
  • body mass index>40 kg/m2
  • patients undergoing bilateral surgery,
  • History of coagulopathies
  • creatinine>1.5 mg/dL
  • American Society of Anesthesia (ASA) III-IV
  • Any contraindication to regional anesthesia
  • Unstable vital data
  • Head or chest trauma will be excluded.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: SOFT block group
needle will be introduced medial to the femoral vein and 3 cm below the skin where 15 mL of bupivacaine 0.25% injected. the obturator nerve, the probe shifted medially, superior to the needle, and directed cranially to the pectineus muscle . Needle withdrawn to the subcutaneous tissue and redirected using out-of-plane toward the deep surface of pectineus, 10 mL of bupivacaine 0.25%will be injected. The sciatic nerve, we use the curvilinear probe, inferior to the needle, and tilted the probe to get the clearest image of the sciatic nerve.The needle will be inserted then withdrawn subcutaneously and directed by an in-plane toward the sciatic nerve deep to the inferior border of the quadratus femoris muscle.20 mL of bupivacaine 0.25% will be injected
needle will be introduced medial to the femoral vein and 3 cm below the skin where 15 mL of bupivacaine 0.25% injected. the obturator nerve, the probe shifted medially, superior to the needle, and directed cranially to the pectineus muscle . Needle withdrawn to the subcutaneous tissue and redirected using out-of-plane toward the deep surface of pectineus, 10 mL of bupivacaine 0.25%will be injected. The sciatic nerve, we use the curvilinear probe, inferior to the needle, and tilted the probe to get the clearest image of the sciatic nerve.The needle will be inserted then withdrawn subcutaneously and directed by an in-plane toward the sciatic nerve deep to the inferior border of the quadratus femoris muscle.20 mL of bupivacaine 0.25% will be injected
Sham Comparator: spinal anesthesia group
patients will receive spinal anesthesia with hyperbaric bupivacaine 0.5% (7.5-10mg). This will be administered via a 25-G spinal needle at L4-L5 or L3-L4 with the patient in the sitting position under complete aseptic conditions.
patients will receive spinal anesthesia with hyperbaric bupivacaine 0.5% (7.5-10mg). This will be administered via a 25-G spinal needle at L4-L5 or L3-L4 with the patient in the sitting position under complete aseptic conditions.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
T- test of the recovery time(duration of analgesia)mean±SD
Time Frame: 3-12 hours
It is the time from the end of local anaesthetic injection to complete resolution of sensory block
3-12 hours

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Review of medical records for postoperative complications
Time Frame: 48 hours after the procedure
persistent parasthesia
48 hours after the procedure
Failure of the block
Time Frame: 50 minutes
general anesthesia will be required to complete surgery.
50 minutes

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Investigators

  • Principal Investigator: Hoda Shokri, MD, Ain Shams University

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

February 10, 2018

Primary Completion (Actual)

January 10, 2019

Study Completion (Actual)

January 10, 2019

Study Registration Dates

First Submitted

February 20, 2018

First Submitted That Met QC Criteria

February 23, 2018

First Posted (Actual)

March 1, 2018

Study Record Updates

Last Update Posted (Actual)

January 24, 2019

Last Update Submitted That Met QC Criteria

January 22, 2019

Last Verified

January 1, 2019

More Information

Terms related to this study

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

YES

IPD Plan Description

study protocol

IPD Sharing Time Frame

5 to 6 months

IPD Sharing Access Criteria

The collected data are coded, tabulated, and statistically analyzed using statistical package for social sciences software, version 17.0 (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics are carried out for numerical parametric data and presented as mean±SD, whereas categorical data are presented as number and percentage. Variables such as demographic data and comorbidities are compared using the χ2-test. A P value less than 0.05 was considered significant.

IPD Sharing Supporting Information Type

  • STUDY_PROTOCOL

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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