MORphine Use in the Fascia Iliaca Compartment Block With UltraSound

Brief Summary

Detailed Description

Proximal femoral fractures are common in the ED. A major challenge in such subjects is pain management. Suboptimal pain control is associated with stress, a prolonged hospital stay and delirium. Pain or fear of pain can limit early mobilisation, an important goal in treatment. Therefore early pain management is essential. Standard analgesic care consists of acetaminophen, opiates and/or Non-steroidal anti-inflammatory drugs (NSAID's). Opiates can cause respiratory depression, constipation, drowsiness, nausea and vomiting. Especially elderly patients are at risk for these side effects Regional nerve blocks are increasingly being adopted as an alternative pain management to systemic analgesia in the ED. One of such is the Fascia Iliaca Compartment Block (FICB). This is safe and simple to perform. Results from studies, despite lacking ultrasound guidance are promising. No permanent disability resulted from the few minor complications that have been reported. These include bladder perforation, pneumoretroperitoneum and neuropathy of the femoral nerve. Furthermore no additional treatment was necessary. Ultrasound prevents occurrence of such complications. The studies that have compared this specific block to standard analgesia have shown that regional anaesthesia may be superior. However these studies have low inclusion numbers and lack of randomisation and/or blinding.. Literature up until now has used the numerical rating scale (NRS) as a primary outcome. Although the NRS is a very trustworthy method of measuring pain, the score is a subjective outcome Morphine consumption on the other hand is more objective. The FICB involves the anatomic space situated at the level of the groin in which important nerves that supply the hip joint lie. Anteriorly the space is covered by the iliac fascia. It is therefore known as the fascia iliaca compartment. By introducing a large volume of local anaesthetic solutions, the femoral, lateral femoral cutaneous and to a lesser extent the obturator nerve are anesthetized. Solutions can spread easily within the compartment. Therefore a safe position injection site can be chosen, minimizing the risk of intravascular injection and nerve damage. The classic position for injection is about 3 centimetres lateral from the femoral nerve. In the original FICB the injection site is determined by using landmarks. The fascia iliaca compartment is then approached by introducing a blunt needle, which enables the physician to feel a 'pop' twice. The first pop is felt when the fascia lata is pierced, the second when the fascia iliaca is passed. Most ED's nowadays have access to ultrasound. When used for FICB placement, the local anaesthetic solution is visualized as it is introduced into the space. Therefore a higher chance of successful placement of agent and a lower risk of complications can be expected. So far no large double blind randomised placebo controlled trials have evaluated morphine use in ultrasound guided placement of local anaesthetic agents with FICB in the ED. This study is designed as such. Total morphine use will be taken as the primary outcome, administered in the form of patient controlled analgesia (PCA).

Primary Outcomes

Secondary Outcomes

• Average of PCA-pump requests for morphine per hour (presses / hour)(Time from FICB placement until operation, up to 24 hours. Time point: each hour)
• Average time to first morphine administration with PCA-pump (minutes)(Time from FICB placement until operation, up to 24 hours.)
• Patients with occurence of NRS > 3.(Time from FICB placement until operation, up to 24 hours. Time point at 24 hours.)
• Difference in pain scores at movement.(Time from FICB placement until operation, up to 24 hours. Time point: each hour)
• Morphine consumption in milligrams per hour at each hour in the time preceding operation. (mg / hour)(Time from FICB placement until operation, up to 24 hours. Time point: each hour)
• Average pain score at different time points.(Time from FICB placement until operation, up to 24 hours. Time point: each hour)
• Number of patients with a delirium in preoperative period.(Time from FICB placement until operation, up to 24 hours. Time point at 24 hours.)
• The number of patients with morphine related side effects.(This will be assessed by the nurse at the rounds each shift up to 3 times daily until operation or up to 24 hours.)
• Number of patients with treatment-related adverse events as assessed by CTCAE v4.0.(Time from FICB placement until operation, up to 24 hours.)
• Time spent on FICB placement in seconds.(The time from needle entering patient, until procedure is terminated by the emergency physician.)