Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : UC29 - UC32 Full Version

Evaluation of Ultrasound-guided Pre-emptive Fascia Iliaca Compartment Block for Postoperative Analgesia in Femur and Hip Fracture Surgeries: A Randomised Controlled Trial


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55137.16479
Tomurthy Sahithi, Rajagopalan Venkatraman, Chinnappan K Swetharamani, Krishnamoorthy Karthik

1. Postgraduate Student, Department of Anaesthesiology, SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India. 2. Professor, Department of Anaesthesiology, SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India. 3. Associate Professor, Department of Anaesthesiology, SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India. 4. Professor, Department of Anaesthesiology, SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India.

Correspondence Address :
Dr. Rajagopalan Venkatraman,
Professor, Department Of Anaesthesiology, SRM Medical College Hospital, Potheri, Kattankulathur, Chennai, Tamil Nadu, India.
E-mail: drvenkat94@gmail.com

Abstract

Introduction: Spinal anaesthesia is the preferred anaesthetic technique for fractures of the hip and femur. Ultrasound-guided Fascia Iliaca Compartment Block (FICB) provides more intense analgesia which can prolong the duration of postoperative analgesia and also mitigate the pain encountered while positioning for spinal anaesthesia.

Aim: To evaluate the efficacy of ultrasound-guided pre-emptive FICB in hip and femur fracture surgeries.

Materials and Methods: This randomized, double-blinded, clinical study was conducted between May 2019 and December 2019, at SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India. Total 66 patients scheduled for hip and femur fracture surgeries under spinal anaesthesia were randomly divided into two groups i.e, group A received Ultrasound-Guided (UG) FICB preoperatively and group B received no block. All the patients received fentanyl 1 mcg/kg intravenous (i.v.) 15 min before spinal anaesthesia. The anaesthesiologist performing spinal anaesthesia graded the score of positioning as 0 as not satisfactory, 1 as satisfactory, 2 as good, 3 as optimal. The time for the first request for analgesia, consumption of analgesics and Visual Analog Scale (VAS) scores for 24 hours postoperatively and any adverse effects were compared between the two groups. Student’s t-test was used to compare continuous data and unpaired t-test for categorical data.

Results: The time for the first request for analgesia was 671.52±66.73 min in group A and 480.3±57.65 min in group B and was statistically significant (p-value <0.0001). In group A, the quality of positioning for spinal anaesthesia was optimal in 13 and good in 14 patients. In group B, it was unsatisfactory in 12 and just satisfactory in four patients (p-value=0.0009). Majority of the patients (24) in group A required three doses of paracetamol, while 26 patients required two doses for group B. The total number of doses for tramadol was 4 in group A, and 17 in group B. The VAS scores were reduced at the 8th and 10th hours following surgery in group A. No adverse effects were encountered in the study.

Conclusion: The FICB prolongs the time to first request for analgesia postoperatively, improves patient positioning for spinal anaesthesia, reduces the consumption of analgesics, and improves VAS scores postoperatively without any adverse effects.

Keywords

Analgesia, Patient positioning, Spinal anaesthesia, Ultrasonography, Visual analog scale

Fractures of the hip and femur are severely painful bone injuries because the periosteum has the lowest pain threshold (1). The inadequate treatment of pain can lead to neurohumoral response leading to adverse cardiac events. Hip fractures are common among the elderly population where increased heart rate and blood pressure are undesirable. This can even lead to fatal cardiac events (2). Hence, adequate pain control is essential in these patients. Also, positioning the patients with hip and femur fractures in a lateral decubitus position or supine for the central neuraxial blockade is extremely onerous and excruciating (3). Adequate analgesia rendered before spinal or epidural anaesthesia can achieve optimal positioning of the patient. This not only escalates the success rate but also bestows comfort to both patients and anaesthesiologists (4).

The pain alleviation ensuing surgeries are usually treated with opioids or Non Steroidal Anti-inflammatory Drugs (NSAIDs). This can lead to renal damage or respiratory depression, nausea, vomiting, and pruritus respectively especially in elderly patients. The peripheral nerve blocks like Femoral Nerve Block (FNB) and Fascia Iliaca Compartment Block (FICB) can provide adequate analgesia preoperatively. This nerve blockade succours in positioning the patient for spinal anaesthesia, extends the duration of analgesia, and diminishes the consumption of opioids postoperatively (5).

In developing countries, most hip and femur fracture surgeries are performed under spinal anaesthesia. But, positioning the patients for spinal anaesthesia is an onus. Singh AP et al., proved that femoral nerve block was superior to intravenous (i.v.) fentanyl in reducing the time for spinal anaesthesia and better Visual Analog Scale (VAS) scores postoperatively in fracture femur surgeries (1). They showed that Ultrasound-Guided (UG) FICB was more effective than femoral nerve block in relieving patient pain during positioning of spinal anaesthesia (3). A meta-analysis demonstrated that FICB was more effective than i.v. analgesics in providing better quality during positioning of spinal anaesthesia (5).

There are only fewer studies studying the efficacy of UG FICB administered pre-emptively, to study the duration of postoperative analgesia and quality of positioning for spinal anaesthesia. Hence, this study was planned to evaluate the effectiveness of pre-emptive ultrasound-guided FICB in hip and femur fracture surgeries. The primary objective was to assess the time for the first request for analgesia. The secondary objectives were to compare positioning scores for spinal anaesthesia, consumption of analgesics for 24 hours postoperatively, VAS scores and adverse effects, if any.

Material and Methods

This randomized, double-blinded clinical study was conducted between May 2019 and December 2019, at SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India. This study was initiated after Institutional Ethical Committee (1378/IEC/2018) assent and registration with Clinical Trial Registry - India (CTRI/2019/04/018488). The study was done in accordance with the Ethical Guidelines of Helsinki declaration.

Inclusion criteria: All patients with American Society of Anesthesiologists (ASA) physical status I or II patients aged between 18 to 75 years, with body mass index between 18 and 25, and scheduled for hip and femur fracture surgeries under spinal anaesthesia were included in the study.

Exclusion criteria: Patients with cardiac, liver, or renal disorders, pregnancy, coagulation disorders, and those with contraindications for spinal anaesthesia were excluded from the study.

Total 66 consecutive patients eligible for the study were randomly split into two groups by using computer-generated random numbers and stored in a sealed, opaque enclosure. The envelope was opened at the start of a case and allocated to that particular group.

• Group A patients received UG FICB before spinal anaesthesia
• Group B patients no intervention was performed

A total of 70 patients were screened, and four patients were excluded for not meeting the inclusion requisites. Total 33 patients were analysed in each group and none of them were lost to follow-up. The CONsolidated Standards of Reporting Trials (CONSORT) flow chart depicting the passage of patients in the study is given in (Table/Fig 1).

Procedure

The anaesthesia was standardized in both groups. An Ultrasonogram machine (Logiq V2, GE Medical Systems, China), with a 5-13 MHz linear probe was utilized for the FICB. Under strict aseptic precautions, the patient was placed in the recumbent position, the ultrasonogram was placed medial to the anterior superior iliac spine to visualize internal oblique and sartorius muscle in a bow-tie fashion. The fascia iliaca and iliacus muscles were identified and 30 mL of 0.5% ropivacaine was injected just below the fascia iliaca. The correct position of the needle {100 mm, 20 G Stimuplex (B Braun) needle} was confirmed by the peeling of the iliacus muscle from the fascia iliaca (Table/Fig 2). The blocks were performed by a single, experienced anaesthesiologist. Patients in both groups received fentanyl 1mcg/kg intravenously for 15 minutes before positioning for spinal anaesthesia. The patients were changed to sitting position 30 minutes after administration of the block in group A. No block was given to patients in group B.

Positioning scores for spinal anaesthesia: The scoring was done by the anaesthesiologist performing spinal anaesthesia according to the positioning of the patient in the sitting position (6):

• 0: not satisfactory,
• 1: satisfactory,
• 2: good,
• 3: optimal

The spinal anaesthesia was administered in both the groups with 0.5% heavy bupivacaine and fentanyl 25 mcg. Patients were monitored using a pulse oximeter, electrocardiogram, and non-invasive blood pressure continuously. All the surgeries were done by a single trauma surgeon.

At the end of the surgery, the patient was transferred to the Postanaesthetic Care Unit (PACU). The patient was monitored by a separate anaesthesiologist, who was not aware of the group involved.

Visual Analogue Scale (VAS): The pain was evaluated by VAS score (7):

• 0 as mild pain,
• 2 as hurts little bit,
• 4 as hurts little more,
• 6 as hurts even more,
• 8 as hurts whole lot and
• 10 as the worst possible pain.

Consumption of analgesics for 24 hours postoperatively: The patients were administered paracetamol 1 gm intravenously (i.v.) when VAS score was ≥3 with the maximum of four doses for 24h. If the pain relief was inadequate at any stage (VAS score was ≥6), tramadol 100mg IV was administered along with ondansetron 4 mg IV. If adequate pain relief (VAS score was ≥6) was not achieved after 30 min of paracetamol and tramadol, fentanyl 1 mcg/kg i.v. was administered. The time for the first request for analgesia was taken as the time taken from the performance of spinal anaesthetic to the first use of paracetamol (VAS score ≥3). The total consumption of paracetamol and tramadol for 24 hrs was recorded. The VAS scores were monitored every two hours during a 24 hrs postoperative period.

Adverse effects: The patients have been monitored for any adverse effects like hypotension, bradycardia, nausea, vomiting, pruritus, respiratory depression, hematoma formation, and infection at the block site.

Pilot study: A pilot study was conducted with 10 patients to determine the sample size, with the time for the first request for analgesia as the primary endpoint. The result was 780.45±96.72 min in group A, and 366.19±54.83 min in group B. Taking the power at 0.9 and the alpha error at 0.05, a sample size of at least 20 patients for each group was computed. A total of 33 patients were included in each group to improve statistical analysis and offset potential drop-outs. Data from the pilot project were not included in the final analysis.

Statistical Analysis

All statistical analysis was accomplished using Statistical Package for Social Science (SPSS) version 17.0 for Microsoft windows. Data were distributed uniformly and categorical data were presented as numbers and percentages of patients. A Chi-square test was used in the comparison of two variables. The continuous data were expressed as mean±Standard Deviation (SD). Independent sample student’s t-test/Mann Whitney tests were used to compare continuous variables between the two groups. A two-tailed p-value < 0.05 was considered statistically significant.

Results

There was no statistically significant difference in age, body mass index, sex, American Society of Anesthesiologists (ASA) physical status, and duration of surgery. The results were tabulated in (Table/Fig 3).

The time for the first request for analgesia was 671.52 ± 66.73 min in group A and 480.3 ± 57.65 min in group B. With a p-value of < 0.0001, the result was statistically significant. The quality of positioning for spinal anaesthesia was good to optimal in about 81.1% of patients in group A. In group B, it was nonsatisfactory in 36.3% of patients, and optimal in 21.2% of patients. It was statistically noteworthy with a p-value of 0.0009 and represented in (Table/Fig 4).

The total consumption of paracetamol was more in group A than the use of tramadol. The total consumption of tramadol was more in group B than paracetamol usage. This is attributed to the lower VAS scores in group A, which determined the type of analgesics administered. The difference in paracetamol consumption was statistically significant with a p-value of <0.0001. The tramadol usage was also statistically significant with a p-value of 0.002. The results were summarized in (Table/Fig 5).

There was a statistically significant difference in VAS scores at the eighth and tenth hours ensuing surgery with pain scores less in group A than group B. There was no significance till six hours and after ten hours in VAS scores postoperatively and given in (Table/Fig 6). No complications were encountered.

Discussion

The positioning of the patient for spinal anaesthesia in sitting or lateral decubitus position is challenging as pain is excruciating due to over-riding fracture ends during movements. FICB performed under ultrasound guidance is easy to learn, has a high success rate and provides intense analgesia when administered pre-emptively in femur fracture patients. The primary aim of the study was to assess the duration of postoperative analgesia. The present randomised clinical study showed that the administration of UG FICB preoperatively not only alleviates the pain of positioning, but also improves patient satisfaction and prolongs the duration of postoperative analgesia.

The FICB prolonged the duration of analgesia postoperatively for more than 11 hours in hip and femur fracture surgeries. The pain relief lasted for nine hours without FICB. Kacha NJ et al., performed performed blind FICB with 30 mL of 0.25% ropivacaine before spinal anaesthesia. They reported the duration of postoperative analgesia to be 428.3 min and were prolonged in the FICB group than the control group. This duration of postoperative analgesia was less than this study and it may be due to not utilizing ultrasound (8). Anaraki AN and Mirzaei K, also proved that FICB delayed the time to first request for rescue analgesia in femur surgery (9).

The quality of positioning for spinal anaesthesia and the anaesthetist satisfaction score was better when FICB was performed. Singh AP et al., demonstrated that a higher number of patients could be positioned optimally in the FICB group than femoral nerve block. They also stated that UG FICB was more effective in relieving pain for positioning of spinal anaesthesia (3). Kacha NJ et al., proved that FICB provided effective pain relief for positioning patients for spinal anaesthesia (8). Hsu YP et al., performed a meta-analysis comparing FICB with intravenous analgesics for positioning before spinal anaesthesia. They studied four randomized controlled trials comprising 141 participants and concluded that FICB can significantly lower the pain scores which facilitate better positioning for spinal anaesthesia (5).

There was a reduction in the consumption of paracetamol and tramadol in the postoperative period. Hsu YP et al., in their meta-analysis, reported that FICB was superior in reducing opioid consumption than intravenous analgesics (5). Bang S et al., observed that UG FICB reduces postoperative fentanyl consumption after hemiarthroplasty (10). Williams H et al., compared standard preoperative analgesia with paracetamol, codeine, and morphine preoperatively with FICB for the neck of femur fractures. They concluded that FICB significantly reduced the consumption of opioids and thereby its adverse effects (11). There was a reduction in VAS scores when FICB was performed preoperatively. Zhou Y et al., proved that VAS scores were reduced in the acute postoperative period when FICB and femoral obturator nerve block were performed for elderly patients with hip fractures (12). Kacha NJ et al., also proved that there was a reduction in VAS scores after FICB (8). Madabushi R et al., demonstrated a reduction in VAS scores (24.72±15.70 mm) in the FICB group than the intravenous fentanyl group (61.22±18.18 mm). This drop-in VAS score was statistically significant (13). The FICB is a relatively safer block and complications were not encountered in any of the studies. Hao J et al., even demonstrated that pre-emptive continuous FICB even reduces the incidence of postoperative delirium in elderly patients (14).

Limitation(s)

All the blocks were performed by an experienced anaesthesiologist and hence failure in blocks was not encountered. The block failure may be encountered in inexperienced hands. Secondly, the obturator nerve may be spared in FICB and a separate block for it may be needed (10),(15),(16). However, adequate pain relief was achieved in most of the patients.

Conclusion

It can be concluded that ultrasound-guided fascia iliaca compartment block administered pre-emptively is effective in femur fractures. It prolongs time to first request for analgesia postoperatively, improves patient positioning for spinal anaesthesia, reduces consumption of analgesics, and improves VAS scores postoperatively, without any adverse effects. The ultrasound-guided FICB should be administered routinely before spinal anaesthesia in femur fracture surgeries.

References

1.
Singh AP, Kohli V, Bajwa SJ. Intravenous analgesia with opioids versus femoral nerve block with 0.2% ropivacaine as preemptive analgesic for fracture femur: A randomized comparative study. Anesth Essays Res. 2016;10(2):338-42. [crossref] [PubMed]
2.
Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N et al. Opioid complications and side effects. Pain Physician. 2008;11(2):105-20. [crossref]
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Singh ND, Ghodki PS. Ultrasound guided fascia iliaca compartment block versus femoral nerve block for positioning for spinal anesthesia in patients with hip fracture. International Journal of Medical Anesthesiology. 2020;3(1): 236-40. [crossref]
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Ranjit S, Pradhan BB. Ultrasound Guided Femoral Nerve Block to Provide Analgesia for Positioning Patients with Femur Fracture Before Subarachnoid Block: Comparison with Intravenous Fentanyl. Kathmandu Univ Med J. 2016;14(54):125-29.
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Hsu YP, Hsu CW, Bai CH, Cheng SW, Chen C. Fascia iliaca compartment block versus intravenous analgesic for positioning of femur fracture patients before a spinal block: A PRISMA-compliant meta-analysis. Medicine (Baltimore). 2018;97(49):13502. [crossref] [PubMed]
6.
Bantie M, Mola S, Girma T, Aweke Z, Neme D, Zemedkun A. Comparing Analgesic Effect of Intravenous Fentanyl, Femoral Nerve Block and Fascia Iliaca Block During Spinal Anesthesia Positioning in Elective Adult Patients Undergoing Femoral Fracture Surgery: a Randomized Controlled Trial. J Pain Res. 2020;13:3139-46. [crossref] [PubMed]
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Venkatraman R, Karthik K, Belinda C, Balaji R. A Randomized Observer-Blinded Controlled Trial to Compare Pre-Emptive with Postoperative Ultrasound-Guided Mandibular Nerve Block for Postoperative Analgesia in Mandibular Fracture Surgeries. Local Reg Anesth. 2021;14:13-20. [crossref] [PubMed]
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Kacha NJ, Jadeja CA, Patel PJ, Chaudhari HB, Jivani JR, Pithadia VS. Comparative Study for Evaluating Efficacy of Fascia Iliaca Compartment Block for Alleviating Pain of Positioning for Spinal Anesthesia in Patients with Hip and Proximal Femur Fractures. Indian J Orthop. 2018;52(2):147-53.
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Anaraki AN, Mirzaei K. The effect of fascia iliaca compartment block versus gabapentin on postoperative pain and morphine consumption in femoral surgery, a prospective, randomized, double-blind study. Indian J Pain. 2014;28:111-16. [crossref]
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Bang S, Chung J, Jeong J, Bak H, Kim D. Efficacy of ultrasound-guided fascia iliaca compartment block after hip hemiarthroplasty: a prospective, randomized trial. Medicine. 2016;95(39):5018. [crossref] [PubMed]
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Williams H, Paringe V, Shenoy S, Michaels P, Ramesh B. Standard preoperative analgesia with or without fascia iliaca compartment block for femoral neck fractures. J Orthop Surg (Hong Kong). 2016;24(1):31-35. [crossref] [PubMed]
12.
Zhou Y, Zhang WC, Chong H, Xi Y, Zheng SQ, Wang G, et al. A Prospective Study to Compare Analgesia from Femoral Obturator Nerve Block with Fascia Iliaca Compartment Block for Acute Preoperative Pain in Elderly Patients with Hip Fracture. Med Sci Monit. 2019;25:8562-70. [crossref] [PubMed]
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Madabushi R, Rajappa GC, Thammanna PP, Iyer SS. Fascia iliaca block vs intravenous fentanyl as an analgesic technique before positioning for spinal anesthesia in patients undergoing surgery for femur fractures-a randomized trial. J Clin Anesth. 2016;35:398-403. [crossref] [PubMed]
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Hao J, Dong B, Zhang J, Luo Z. Pre-emptive analgesia with continuous fascia iliaca compartment block reduces postoperative delirium in elderly patients with hip fracture. A randomized controlled trial. Saudi Med J. 2019;40(9):901-06. [crossref] [PubMed]
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Eyi YE, Arziman I, Kaldirim U, Tuncer SK. Fascia iliaca compartment block in the reduction of dislocation of total hip arthroplasty. Am J Emerg Med. 2014;32(9):1139. [crossref] [PubMed]
16.
Shariat AN, Hadzic A, Xu D, Shastri U, Kwofie K, Gandhi K, et al. Fascia lliaca block for analgesia after hip arthroplasty: a randomized double-blind, placebo-controlled trial. Reg Anesth Pain Med. 2013;38(3):201-05. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/55137.16479

Date of Submission: Jan 22, 2022
Date of Peer Review: Feb 25, 2022
Date of Acceptance: Mar 16, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 25, 2022
• Manual Googling: Mar 15, 2022
• iThenticate Software: Mar 22, 2022 (12%)

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