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

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On Sep 2018




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On Sep 2018




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"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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Saraswati Dental College
Lucknow
On Sep 2018




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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.


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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.
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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 : May | Volume : 16 | Issue : 5 | Page : UC01 - UC04 Full Version

Effectiveness of Femoral Nerve Block Versus Intravenous Nalbuphine in Positioning of Patients with Intertrochanteric Fractures for Spinal Anaesthesia: A Randomised Clinical Study


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55841.16301
Amit Pradhan, Amrita Panda, Pragna Doppalapudi

1. Professor, Department of Anaesthesiology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. 2. Professor, Department of Anaesthesiology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. 3. Junior Resident, Department of Anaesthesiology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India.

Correspondence Address :
Dr. Amrita Panda,
Professor, Department of Anaesthesiology, Kalinga Institute of Medical Sciences, Bhubaneswar-751024, Odisha, India.
E-mail: amritapanda1323@gmail.com

Abstract

Introduction: Femoral fracture is a common entity in all age groups. It is more common in elderly, and is a painful condition. Various modalities like peripheral nerve blocks, intravenous opioids can mitigate the pain associated with it which is deterrent to ideal patient positioning for spinal anaesthesia.

Aim: To compare the effectiveness of Femoral Nerve Block (FNB) versus Intravenous Nalbuphine (IVN) in positioning of patients with intertrochanteric fracture for spinal anaesthesia.

Materials and Methods: A randomised clinical study was conducted in 70 patients of American Society of Anesthesiologists (ASA) physical status I and II, with intertrochanteric fractures posted for surgery under Subarachnoid block. Group IVN received intravenous Nalbuphine at dose of 0.1 mg/kg, and Group FNB received femoral nerve block with 20 mL of 0.2% Ropivacaine 15 minutes, prior to positioning of patients for Subarachnoid block. The ease of patient positioning was assessed by the pain relief observed during positioning for spinal anaesthesia, and by means of anesthesiologist satisfaction score. Time taken to position the patients during spinal anesthesia, and patient satisfaction scores were also measured. Independent ‘t’ test and Mann-Whitney U tests were used for the analysis.

Results: The Visual Analogue Scale (VAS) score achieved during positioning of patients for subarachnoid block was significantly better in FNB (3.87±0.99), as compared to IVN (5.09 ±1.23). No significant differences were observed between both the groups regarding anesthesiologist’s satisfaction score, (p=0.11). Time taken for positioning of patients for spinal anaesthesia in seconds (p=0.69), and patient satisfaction score (p=0.08) were also comparable between both groups of patients.

Conclusion: FNB is more effective for positioning of patients of intertrochanteric fractures for spinal anaesthesia. Although either of the techniques can be adopted for improving patient care, FNB may have an edge over IVN.

Keywords

Nalbuphine, Pain relief, Patient positioning, Subarachnoid block

In proximal femur fractures surgical fixation is undertaken early to enhance quicker recovery of elderly patients, and help prevent major complications of prolonged immobilisation like pneumonia and deep vein thrombosis. Administering anaesthesia to this population poses multiple challenges to the anaesthesiologist because of presence of multiple factors -one of them being pain and thus is unsuitable for regional anaesthesia. Bone pain is derived from noxious stimulation of the periosteum or bone marrow. Adequate pain management is necessary to avoid severe psychological distress in patients (1).

Subarachnoid block is the preferred technique and correct positioning is a prerequisite (2). There is inadequate evidences comparing the use of opioids (like nalbuphine) and FNB to recommend one technique over the other and as so far there is only one study by Durrani HD et al., they compared FNB using 15 mL lignocaine with adrenaline versus a fixed dose of 6 mg IVN (3). They observed that VAS score during positioning was significantly less in FNB versus IVN time taken to perform spinal block was shorter and quality of patient positioning was also better in FNB as compared to IVN.Thus,the femoral nerve block was more effective than IVN and improved patient positioning for administration of spinal anaesthesia.

The present study aimed to evaluate the effectiveness of FNB using 0.2% ropivacaine versus IVN 0.1 mg/kg for positioning of patients with intertrochanteric fracture surgery under spinal anaesthesia. The primary objective was to assess the ease of patient positioning for spinal anaesthesia which was elicited by the degree of pain relief (VAS score) achieved during patient positioning, and by anaesthesiologist satisfaction score. The secondary objective was to assess the time taken in seconds for patient positioning prior to spinal anaesthesia and patient satisfaction score.

Material and Methods

The randomised clinical trial was conducted in the Department of Anaesthesiology at Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. The duration of study was from September 2019 - September 2021 (two years). The Institutional Ethics Committee (IEC) had approved the study (IEC No: KIIT/KIMS/IEC/131/2019), and it is also registered in the Clinical Trial Registry of India (CTRI/2019/10/021579). Written informed consent was obtained from every patient prior to study.

Inclusion criteria: Subjects of age 18-80 years of either gender, ASA I,II category, scheduled for intertrochanteric fracture surgeries under central neuraxial blockade were included.

Exclusion criteria: Subjects with any contra-indications for central neuraxial blockade, femoral nerve blockade or use of opioids/local anaesthetics. ASA III and IV patients, history of polytrauma, infection over injection site and refusal for participation were excluded.

Sample size: Sample size was calculated with reference to the study by Durrani HD et al., (3). The quality of patient positioning score during spinal anaesthesia as depicted by mean±Standard Deviation (SD) was (2.45±0.55) in FNB group and (1.88±0.80) in the IVN group of patients. Assuming this reference values d=0.83, the minimum required sample size at 5% level of significance and 80% power was at least 32 in each group. Taking attrition at 10%, total 70 patients were included in present study i.e., 35 in each group.

Seventy subjects were randomised into two groups by means of computer generated random number table in a ratio of 1:1. Patient allocation was done using opaque sealed envelope technique.

The IVN in a dose of 0.1 mg/kg was administered to one group of patients and the other group patients were administered Ultrasound guided FNB. Nalbuphine 1 mg was diluted to 10 mL with distilled water and was administered in dose 0.1 mg/kg intravenously to the respective group of patients. Ultrasound guided FNB with 20 mL of 0.2% ropivacaine was given, using high frequency (5-12 MHz), linear (Sonosite Edge II ultrasound system FUJIFILM Medical system, USA) probe to visualise the femoral nerve immediately lateral to the femoral artery. USG probe was placed in the inguinal crease parallel to the inguinal ligament. Using the in plane technique of needle placement the stimuplex 10 cm needle was advanced parallel to the USG beam lateral to femoral artery pulsation until it reached the femoral nerve. Local anesthetic 20 mL 0.2% ropivacaine was deposited around the femoral nerve and its spread was visualised on the ultrasound screen. The anesthesiologist who performed the subarachnoid block administered the femoral nerve block. (Table/Fig 1) and (Table/Fig 2) depict the ultrasonography, and procedural images. The study was not blinded. There were no complications like inadvertent vascular injury, or local anesthetic toxicity or residual femoral nerve neuropathy while performing FNB.

Study Procedure

Either of the procedures was performed 15 minutes prior to positioning for spinal anaesthesia. Thereafter, under strict aseptic conditions, subarachnoid block was given at L3-L4 or L2-L3 level using midline approach in sitting posture with 0.5% hyperbaric bupivacaine 3 mL. The time taken to perform the subarachnoid block was within 2-3 minutes. Then, haemodynamic variables- Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial pressure (MAP), peripheral oxygen saturation (SpO2) were monitored before procedure and at time intervals of 2 minutes, 5 minutes, 10 minutes, 15 minutes, 20 minutes after procedure.

The primary study outcome was to measure ease of patients positioning as assessed by pain relief using VAS score before procedure and during positioning for subarachnoid block, and by anesthesiologist satisfaction score (0-4) (0-Not satisfactory; 1-satisfactory; 2-good; 3-optimal; 4-excellent) during patients positioning (3).

The secondary outcome was to assess :

a) Time duration (seconds) for positioning for the spinal anaesthesia
b) Satisfaction of patient was also recorded as binary variable yes/no.

Statistical Analysis

Statistical analysis was done by using the International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) software version 23.0. Data for continuous variable was presented as mean±SD or Median Interquartile Range (IQR) and the categorical variables were presented as frequency and percentage. Independent t-test/ Mann-Whitney U-test was done to compare the continuous variables based on the distribution of data. Chi-square/Fisher exact test was done to check the association between two categorical variables. The p-value <0.05 was considered as statistically significant. The data was checked for normality using Kolmogorov-Smirnov and Shapiro-Wilk test.

Results

A total of 70 patients who satisfied inclusion criteria were assessed and randomised for study, 35 in each group. Two subjects in IVN Group and three in FNB Group refused participation and were excluded. The total number of participants who had received intervention was 33 in IVN group, and 32 in FNB group (Table/Fig 3).

The distribution of age and gender was similar across IVN and FNB groups (p>0.05) (Table/Fig 4).

VAS score was significantly less in FNB group of patients during positioning. The ease of patient positioning between both group as assessed by VAS during positioning was highly significant (p>0.001). The time taken for positioning of patients for spinal anesthesia (in seconds) showed no statistical difference between both groups (p=0.69). Also, the time taken to perform spinal anaesthesia (in seconds) showed no statistically significant difference between both groups (p=0.25). Anaesthesiologist satisfaction in FNB group and IVN group was also comparable (p=0.11). Patient satisfaction between FNB group and IVN group is also similar between both groups (p=0.08) shown in (Table/Fig 5).

(Table/Fig 6) shows the comparison of vital parameters between the two groups. All these haemodynamic variables were not statistically significant between groups before procedure (p>0.05). During positioning (at 15 min) mean value of all these parameters was also similar between the two groups except MAP. MAP in IVN group during positioning was significantly higher as compared to FNB group (91.42±14.44 vs 81.74±17.08; p-value <0.05).

Discussion

Spinal anesthesia is the preferred technique for femur fracture surgeries as it is more advantageous than general anaesthesia in providing early mobility, less chances of deep vein thrombosis and helps avoid respiratory complications associated with old age. For improving positioning for subarachnoid block, though opioids are common in use, they are not devoid of adverse effects like cognitive impairment, respiratory depression and vomiting, urinary retention especially in the elderly. Alternatively, peripheral nerve blocks like FNB, fascia iliaca compartment block are practiced for better pain relief and to improve patient positioning. They can be performed through techniques like landmark guided approach, use of peripheral nerve stimulator or ultrasound for identification of nerves. FNB when guided by ultrasound aids in getting the exact location of the nerve, hence helps reducing the volume of local anaesthetic solution, hastens the onset and improves the quality of block compared to conventional peripheral nerve stimulator technique (4). Some researchers found no statistically significant difference between both the groups with respect to age, similar to the present study. (5),(6) FNB provides better analgesia for patient positioning in subarachnoid block. Utility of this FNB, administered 15 minutes prior to positioning of patients, is well proved in terms of its analgesic efficacy. This is well supported by several other studies (3),(5),(7),(8) However, Iamaroon A et al., did not find any significant difference in the VAS scores or benefit of FNB over IV Fentanyl (9). They used 0.3% bupivacaine for FNB and positioned the patients 15 min after block. In the present study, 0.2% ropivacaine and IVN was used. The present authors chose to compare the concentration 3of local anaesthetic (0.2% ropivacaine) versus the mentioned dose of IVN (0.1 mg/kg b.w) as per institutional practice and availability of drugs.

The most important finding in the present study was the ease of patient positioning as also assessed by the anaesthesiologists. It was better in the FNB group when compared to IVN group was comparable. These results however, do not corroborate with some studies, which revealed quality of patient positioning was better with peripheral nerve blocks. (7),(10),(11),(12),(13). These authors used different concentration of local anaesthetics and shorter-acting opioids like fentanyl.

The optimal position achieved to perform subarachnoid block in both the groups was due to quick onset of action of drugs (Ropivacaine and Nalbuphine) which provided adequate analgesia after similar time interval. In this study, the authors chose the sitting position for subarachnoid block as this is an institutional practice and was easier to identify the landmarks. A similar study concluded that fascia iliaca compartment block enables better hip flexion and helps to improve the ability for adequate sitting position during subarachnoid block (14).

The difference in patient satisfaction was also statistically insignificant between both the groups (p=0.08). These results are dissimilar to the studies by Singh AP et al., Purohit S et al., where better patient satisfaction score was achieved in FNB group (15),(16). The difference in results is due to use of different concentration of local anaesthetics and short acting opioids.

The time taken for positioning (in seconds) of patients between both the groups had no statistically significant difference (p=0.69) too. In addition, the difference in time taken to perform subarachnoid block (time from beginning of positioning to end of spinal) between both groups was statistically insignificant (p-value=0.25). This indicates that both techniques reduce the time taken for administering subarachnoid block equally. Durrani HD et al., also proved that though statistically significant, clinically, time to perform spinal in FNB group was not significantly shorter than IVN group (3). Purohit S et al., suggested that FNB produced relaxation of the quadriceps muscle, provided better analgesia for positioning and a shorter time to perform spinal anesthesia (16). The difference in the present study results, related to the time taken for performance of subarachnoid block, might be due to delay between trauma and surgery which may have had an unpredictable effect on pain in these patients. Reasons for delay in surgery include waiting for preoperative test results, medical stabilisation and availability of the surgeon or operating room. Most of the studies were conducted on all types of femur fracture surgery and hip fracture, but this study specifically considered intertrochanteric fractures.

With respect to haemodynamic parameters, the present study findings corroborate with the results of Yun MJ et al., (17). However, the mean arterial pressure was found to be significantly lower after 15 minutes of study intervention in both the groups (p=0.017). Adequate pain relief measures provided well controlled hemodynamics.

Limitation(s)

The patients were not followed-up for postoperative pain relief. So, the total consumption of analgesics for pain relief was not assessed over 24 hours. Neither the patients nor the principal investigator was blinded in the study which could have lead to observer bias. Also, the time interval between occurrence of trauma and execution of surgery was not uniform among the patients.

Conclusion

In terms of pain relief prior to and after positioning of patients of intertrochanteric fractures for subarachnoid block, FNB is more effective than IVN. In terms of other parameters (like haemodynamics, patient satisfaction, time taken for positioning, time taken to perform subarachnoid block), both FNB and IVN are equally efficacious. This study, compared both the techniques and can help in formulating an approach to make patient positioning comfortable and pain free during administration of central neuraxial block. Hence, it is recommended that either of the techniques can be adopted for providing better care of such patients in a tertiary healthcare centre, although FNB may have an edge over IVN.

References

1.
Nencini S, Ivanusic JJ. The physiology of bone pain. How much do we really know? Front Physiol. 2016; 7:157. [crossref] [PubMed]
2.
Thomas MS, Sullivan G, Hall JE. A national survey into the peri-operative anaesthetic management ofpatients presenting for surgical correction of a fractured neck of femur. Anaesthesia. 2008; 63:250. [crossref] [PubMed]
3.
Durrani HD, Butt KJ, Khosa AH, Umer A, Pervaiz M. Pain relief during positioning for spinal anaesthesia in patients with femoral fracture: A comparison between femoral nerve bock and intravenous nalbuphine. Pak J Med Heal Sc 2013; 7: 928.
4.
Marhofer P, Schrögendorfer K, Wallner T, Koinig H, Mayer N, Kapral S. Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med. 1998; 23(6):584-88. [crossref]
5.
Dolatabadi A, Hatamabadi A, Shahrami H, Shojaee M. Femoral Nerve Block in Patients with Femoral Shaft Fractures in Emergency Department. J Basic Appl Sci Res. 2013; 3(11):15.
6.
Madabushi R, Rajappa GC, Thammanna PP, Iyer SS. Fascia iliaca block vs intravenous fentanyl as an analgesic technique before positioning for spinal anaesthesia in patients undergoing surgery for femur fractures-A randomized trial. J Clin Anesth. 2016;35:398. [crossref] [PubMed]
7.
Jadon A, Kedia SK, Dixit S, Chakraborty S. Comparative evaluation of femoral nerve block and intravenous fentanyl for positioning during spinal anaesthesia in surgery of femur fracture. Indian J Anaesth. 2014; 58:705-08. [crossref] [PubMed]
8.
Reddy ED, Rao BD. Comparative study of efficacy of femoral nerve block and IV fentanyl for positioning during femur fracture surgery. Int Surg J. 2016;3:321. [crossref]
9.
Iamaroon A, Raksakietisak M, Halilamien P, Hongsawad J, Boonsararuxsapong K. Femoral nerve block versus fentanyl: Analgesia for positioning patients with fractured femur. Local Reg Anesth. 2010;3:21-26. [crossref] [PubMed]
10.
Babu S, Gupta BK, Gautam GK. A comparative study for post operative analgesia in the emergency laparotomies: Thoracic epidural ropivacaine with nalbuphine and ropivacaine with butorphanol. Anesth Essays Res. 2017;11(1):155-59. [crossref] [PubMed]
11.
Kumar A, Sinha C, Kumar A, Kumari P, Bhat D, Bhadani UK. Positioning of fracture femur patients for spinal anaesthesia: Femoral nerve block or intravenous fentanyl? Bali Journal of Anesthesiology. 2018; 2(3): 28761. [crossref]
12.
Korra AN, Brahmaroutu RK, Rao ASK. Comparative evaluation between fascia iliaca compartment block and intravenous fentanyl administration for painless positioning during spinal Anaesthesia in fracture femur surgeries: A randomized controlled study . Int J Me Anesthesiology. 2020;3(1):306. [crossref]
13.
Reddy KM, Reddy VV, Bhavana B. Comparative evaluation offemoral nerve block & intravenous fentanly for positioning during spinal anesthesia in surgery of femur fractures. International Journal of Contemporary Medical Research 2020;7(7):1-4. [crossref]
14.
Candal-Couto JJ, McVie JL, Haslam N, Innes AR, Rushmer J. Pre-operative analgesia for patients with femoral neck fractures using a modified fascia iliaca block technique Injury. 2005; 36(4):505–10. [crossref] [PubMed]
15.
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;10:338-42. [crossref] [PubMed]
16.
Purohit S, Ejjapuredi S, Badami RN. Positioning for regional anaesthesia in femur fracture surgeries: how effective is femoral nerve block? A randomised control study. Int J Res Med Sci. 2017;5:3590-95. [crossref]
17.
Yun MJ, Kim YH, Han MK, Kim JH, Hwang JW, Do SH. Analgesia before a spinal block for femoral neck fracture: Fascia iliaca compartment block. Acta Anaesthesiol Scand. 2009;53(10):1282-87. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/55841.16301

Date of Submission: Feb 22, 2022
Date of Peer Review: Mar 09, 2022
Date of Acceptance: Mar 31, 2022
Date of Publishing: May 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: Feb 28, 2022
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• iThenticate Software: Apr 14, 2022 (10%)

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