Continuous Fascia Iliaca Block for Acute Hip Fractures

Continuous Fascia Iliaca Block for Acute Hip Fractures: a Randomized Controlled Pilot Study

Hip fractures are a major cause of morbidity and mortality in the elderly with over 30,000 hip fractures occuring in Canada annually and over 1300 in Saskatchewan. The estimated cost associated with hip fractures is over $600 million nationally and 28 million dollars in Saskatchewan. Hip fractures cause a great deal of pain and immobility and are mainly treated with surgical fixation. In the perioperative period, hip fracture patients are treated mainly with opioids and other adjuncts such as NSAIDS and acetaminophen. Opioid consumption in the elderly population can predispose to delirium and respiratory complications such as atelectasis, respiratory depression, and pneumonia.

Fascia iliaca blocks have been shown to be an effective mode of analgesia for patients with hip fractures, but are underutilized for varying reasons including culture of practice, expertise with performing the block, and having a dedicated service to do so.

This study aims to compare the efficacy of fascia iliaca blocks to standard treatment (opioids) in the management of pain in hip fracture patients with a particular focus on outcomes such as the incidence of delirium, respiratory complications, and length of stay in hospital. Our idea is that if we can reduce the amount of opioids these patients receive then they will have improved pain control, fewer respiratory complications, earlier time to mobilizing, and shorter hospital stays. As far as we are aware this relation has not been well studied.

Study Overview

• Status: Completed
• Conditions: Pain; Delirium; Hip Fractures; Neuromuscular Blockade; Respiratory Morbidity; Fascia Iliaca Block
• Intervention / Treatment: Procedure: Continuous fascia iliaca block; Drug: Ropivacaine

Detailed Description

This study is a prospective randomized controlled non-blinded pilot study.

Recruitment and Randomization: fifty adult patients with hip fractures for surgical fixation presenting to Royal University Hospital (RUH), Saskatoon, Saskatchewan, will be recruited. The exclusion criteria are:

• American Society of Anesthesiologists (ASA) score >3
• Other injuries that interfere with block positioning and assessment of pain
• Local anesthetic allergy
• Open fracture
• Moderate to severe pre-operative delirium (interfering with consent and assessment)
• Sepsis at site of injection
• Anticoagulation with warfarin or anti-Xa inhibitors
• Age less than 65 years

Patients will be randomized into one of two research arms: Continuous Fascia Iliaca block (cFIB) vs standard treatment (opioids). It is important to note here is that patients receiving cFIBs will have standard treatment orders available in the event of block failure, and opioid consumption will be monitored.

Methods:

Patients with hip fractures presenting to RUH will be approached by a member of the study team for consent to participate in the study. After consent is obtained patients will be randomised to either arm of the study group. The cFIB group will receive an ultrasound guided cFIB and standard treatment orders as backup in the event of block failure. The standard treatment group will receive only standard treatment orders which include a combination of opioids, NSAIDS, acetaminophen, and other adjuncts for analgesia.

The CFIB group will receive an initial bolus of 40 cc of 0.125% Ropivacaine followed by an infusion of 10 cc/hr of 0.2% ropivacaine until the time of surgery. Immediately pre-operatively, the anesthesiologist performing the case will bolus the catheter with 40 cc of 0.125% ropivacaine and discontinue the catheter.

Data collection: Demographic and epidemiologic data will be collected for both groups at the time of recruitment. Patients will be followed from the time of enrollment until the time of discharge from hospital. A member of the study team will visit daily and assess the patients for delirium using the Confusion Assessment Method (CAM)-ICU tool, which is a validated delirium assessment tool. Pain scores will be obtained after block insertion and twice a day until surgical fixation takes place. Pain scores will be assessed in the supine, semi recumbent, and upright position, and with active movement. Opioid consumption will be recorded as morphine equivalents for the entire length of hospital stay. The incidence of side effects of opioids will be recorded including : Nausea, vomiting, pruritis, constipation, and urinary retention.

The length of time from surgery until ready to discharge will be recorded.

It is difficult to directly measure respiratory complications. As a surrogate for respiratory complications the following data will be collected:

• Oxygen requirements pre and post operatively
• Pre and post operative need for positive pressure ventilation (CPAP, BiPAP)
• Radiographic evidence of atelectasis or pneumonia
• Trends in oxygen saturation as measured by pulse oximetry Data collection is projected to be completed by July 1st 2018

Data analysis: Parametric data will be reported as a mean +/- standard deviation, along with confidence intervals. Means will be used to estimate effect size and these values will then be used in power calculations and sample size estimation for future studies. In addition, the unpaired t-test will be used to test for significant difference between groups. The incidence of adverse events will be recorded and presented with descriptive statistics. Data analysis is projected to be completed by October 2018

Significance:

Fascia Iliaca blocks have already been shown to improve pain in hip fracture patents. Our theory is that if we can effectively manage pain with cFIBs we can reduce the amount of opioids patients receive in the perioperative period. This could lead to reduced complications from opioids, improved patient positioning, improved patient mobility, and earlier time to discharge which would have a great impact on patient experience and cost of care.

• Study Type: Interventional
• Enrollment (Actual): 30
• Phase: Phase 4

Contacts and Locations

Study Locations

• Canada
  • Saskatchewan
    • Saskatoon, Saskatchewan, Canada, S7N 0W8
      • Royal University Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 65 years and older (Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Adults age greater than or equal to 65 years old with acute hip fracture

Exclusion Criteria:

• ASA greater than or equal to 4
• Open fractures
• Other concomitant injuries that may interfere with positioning or pain scores
• Local anesthetic allergy
• Delirium at the time of consent
• Pre-existing cognitive impairment
• Infection at the site of injection for cFIB
• Previous surgery in femoral triangle
• Warfarin or Anti-Xa inhibitor use
• Long-term opioid use
• Intraoperative complications

Study Plan

How is the study designed?

Design Details

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

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Standard Treatment; Patients in this group will receive standard treatment orders which include a combination of opioids, NSAIDs, acetaminophen, and other adjuncts for analgesia.
Experimental: Continuous fascia iliaca block; The cFIB group will receive an ultrasound guided cFIB and standard treatment orders as backup in the event of block failure. The cFIB group will receive an initial bolus of 40 cc of 0.25% Ropivacaine followed by an infusion of 8 cc/hr until the time of surgery. Immediately pre-operatively, the anesthesiologist performing the case will bolus the catheter 40 cc of 0.25% ropivacaine and discontinue the catheter.	Procedure: Continuous fascia iliaca block; Regional nerve block performed under ultrasound guidance. A catheter will be left in place to allow ongoing infusion of local anesthetic.; Drug: Ropivacaine; Ropivacaine local anesthetic will be used for the fascia iliaca block

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Respiratory complications	Use of supplemental oxygen, need for positive pressure ventilation, decreased oxygen saturations, radiographic evidence of atelectasis or pneumonia	During hospital stay, up to 1 month

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain score	Subjective pain score on 1-10 visual analog scale in supine, semi-recumbent, upright positions, and with active movement	During hospital stay, up to 1 month
Opioid side effects	Incidence of nausea, vomiting, pruritus, constipation, and urinary retention will be recorded	During hospital stay, up to 1 month
30 day mortality	Status, living or deceased, at 30 days post op	Will be collected from hospital record, at up to 3 months after enrolment.
Delirium	CAM-ICU scoring system will be used daily to measure delirium	During hospital stay, up to 1 month
Post op length of stay	Will be measured as number of days in hospital from date of admission until ready for discharge	During hospital stay, up to 1 month

Collaborators and Investigators

• Sponsor: University of Saskatchewan
• Investigators: Principal Investigator: Brian Brownbridge, MD, University of Saskatchewan; Principal Investigator: Churao Yang, MD, University of Saskatchewan

Publications and helpful links

General Publications

• Guay J, Kopp S. Peripheral nerve blocks for hip fractures in adults. Cochrane Database Syst Rev. 2020 Nov 25;11(11):CD001159. doi: 10.1002/14651858.CD001159.pub3.

Study record dates

Study Major Dates

• Study Start (Actual): May 7, 2018
• Primary Completion (Actual): March 31, 2019
• Study Completion (Actual): May 1, 2019

Study Registration Dates

• First Submitted: April 27, 2018
• First Submitted That Met QC Criteria: July 13, 2018
• First Posted (Actual): July 17, 2018

Study Record Updates

• Last Update Posted (Actual): May 21, 2019
• Last Update Submitted That Met QC Criteria: May 19, 2019
• Last Verified: May 1, 2019

More Information

Terms related to this study

• Keywords: hip fracture; neuromuscular blockade; fascia iliaca block; continuous fascia iliaca block
• Additional Relevant MeSH Terms: Wounds and Injuries; Leg Injuries; Femoral Fractures; Hip Injuries; Fractures, Bone; Hip Fractures; Physiological Effects of Drugs; Central Nervous System Depressants; Peripheral Nervous System Agents; Sensory System Agents; Anesthetics; Anesthetics, Local; Ropivacaine
• Other Study ID Numbers: Bio 17-267

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No
• IPD Plan Description: We will not be sharing individual participant data.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No