Suprainguinal fascia iliaca with pericapsular nerve group block for fractured neck of femur vs. traditional approaches : a better way?

Abstract

Patients presenting with fractured neck of femur are predominantly elderly with often acutely deranged physiology, multiple comorbidities and limited physiological reserve. This places them at high risk of morbidity associated with surgery and emphasises the importance of optimum anaesthetic management. No clear evidence supports any single anaesthetic technique [1] and so considerable variation in peri-operative management exists. Peripheral nerve blockade reduces opioid requirements and total intravenous anaesthesia (TIVA) eliminates exposure to volatile anaesthetics that have been implicated in postoperative cognitive decline (POCD) and delirium [2]. For the purposes of this study, intervention refers to ultrasound-guided suprainguinal fascia iliaca (SIFI) and pericapsular nerve group (PENG) block with TIVA whereas control refers to all other anaesthetic techniques recorded.

Methods

An observational study was undertaken comparing patient outcome following emergency surgery for fractured neck of femur. Sixteen consecutive patients recruited prospectively to the intervention group from our scheduled trauma sessions from January to May 2019. Control patients were selected retrospectively from all trauma lists during the same period using online random number generation software to a total of 16. Patients were followed up manually by review of ward notes and drug charts.

Results

Group demographics were comparable in the control and intervention groups, with hemiarthroplasty being the most common operative procedure overall. Anaesthetic technique in the control group was predominantly spinal or volatile general anaesthesia with combinations of no block, fascia iliac and/or femoral nerve block. Total 24-h postoperative morphine administration was greater in the control group. In the control group, pain was an issue for five patients and three patients suffered from delirium. There were no documented issues in the intervention group.

Discussion

Our results suggest that ultrasound-guided regional anaesthesia targeting the lateral femoral cutaneous nerve of the thigh in combination with articular branches of the femoral and obturator nerves through the recently described PENG block has a place in combination with TIVA as an established protocol for anaesthetic in fractured neck of femur. Patients in this group required no intra-operative morphine and had greatly reduced analgesic requirements with no reported issues in the postoperative period.