Rev. Bras. Anestesiol. vol.67 número1

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

REVIEW

ARTICLE

Femoral

nerve

block

versus

intravenous

fentanyl

in

adult

patients

with

hip

fractures

---

a

systematic

review

Flávia

Vieira

Guimarães

Hartmann

,

Maria

Rita

Carvalho

Garbi

Novaes

,

Marta

Rodrigues

de

Carvalho

a_{HospitaldeBasedoDistritoFederal,Brasília,DF,Brazil} b_{HospitalMilitardeÁreadeBrasília,Brasília,DF,Brazil}

c_{FundacãodeEnsinoePesquisaemCiênciasdaSaúde,Brasília,DF,Brazil} d_{EscolaSuperiordeCiênciasdaSaúde,Brasília,DF,Brazil}

e_{FarmáciaHospitalar,DepartamentodeSaúde,Brasília,DF,Brazil} f_{UniversidaddelChile,Santiago,Chile}

g_{Fundac¸ãodeEnsinoePesquisaemCiênciasdaSaúde,EscolaSuperiordeCiênciasdaSaúde,Brasília,DF,Brazil}

Received29June2015;accepted25August2015 Availableonline19April2016

KEYWORDS

Hipfractures; Femoralnerveblock; Analgesia;

Fentanyl

Abstract

Background: Hipfracturesconfigureanimportantpublichealthissueandareassociatedwith highmortalitytaxesandloseoffunctionality.Hipfracturesrefertoafractureoccurringbetween the edge of the femoral head and5cm below the lessertrochanter. Theyare common in orthopedic emergencies.The number ofproximal femoral fracturesis likelytoincrease as thepopulationages.Theaveragecostofcareduringtheinitialhospitalizationforhip frac-turecanbeestimatedaboutUS$7,000perpatient.Femoralfracturesarepainfulandneed immediateadequateanalgesia.Treatingpainfemoralfracturesisdifficultbecausethereare limitednumbersofanalgesicsavailable,manyofwhichhavesideeffectsthatcanlimittheir use.Opiatesarethemostuseddrugs,buttheycanbringsomecomplications.Inthiscontext, femoralnerveblockscanbeasafealternative.Itisaspecificregionalanesthetic technique usedbydoctorsinemergencymedicinetoprovideanesthesiaandanalgesiaoftheaffectedleg.

Objective: Tocomparetheanalgesicefficacyofintravenousfentanylversusfemoralnerveblock beforepositioningtoperformspinalanesthesiainpatientswithfemoralfracturesassessedby PainScales.

Methods:Asystematicreviewofscientificliteraturewasconducted.Studiesdescribedas ran-domizedcontrolledtrialscomparingfemoralnerveblockandtraditionalfentanylareincluded. Tworeviewers(MRandFH)independentlyassessedpotentiallyeligibletrialsforinclusion.The methodologyassessmentwasbasedonthetooldevelopedbytheCochraneCollaborationfor assessmentofbiasfor randomizedcontrolledtrials.TheCochraneLibrary,Pubmed,Medline andLilacsweresearchedforallarticlespublished,withoutrestrictionoflanguageortime.

∗_{Correspondingauthor.}

E-mail:flaviahartmann@bol.com.br(F.V.Hartmann).

http://dx.doi.org/10.1016/j.bjane.2015.08.017

Results:Twostudieswereincludedinthisreview.Nerveblockadeseemedtobemoreeffective thanintravenousfentanylforpreventingpaininpatientssufferingfromafemoralfracture.It alsoreducedtheuseofadditionalanalgesiaandmadelowertheriskforsystemiccomplications. Femoralnerveblockreducedthetimetoperformspinalanesthesiatothepatientwhowillbe subjectedtosurgeryandfacilitatethesittingpositionforthis.

Conclusion:Theuseoffemoralnerveblockcanreducethelevelofpainandtheneedfor addi-tionalanalgesia.Therearelessadversesystemiceventsassociatedwiththisandtheprocedure itselfdoesnotoffergreaterrisks.Morestudiesarerequiredforfurtherconclusions.

©2016PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradeAnestesiologia. Thisisanopenaccess articleundertheCCBY-NC-NDlicense(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

PALAVRAS-CHAVE

Fraturasdequadril; Bloqueiodonervo femoral;

Analgesia; Fentanil

Bloqueiodonervofemoralversusfentanilporviavenosaempacientesadultoscom

fraturasdequadril---revisãosistemática

Resumo

Justificativa:Asfraturasdequadrilsãoumaquestãoimportantedesaúdepúblicaeestão asso-ciadasaaltastaxasdemortalidadeeperdadefuncionalidade.Asfraturasdequadrilreferem-se aumafraturaqueocorreentreabordadacabec¸afemoralecincocentímetrosabaixodo trocan-termenoresãocomunsememergênciasortopédicas.Onúmerodefraturasdofêmurproximal provavelmenteaumentaráàmedidaqueapopulac¸ãoenvelhece.Ocustomédiodaassistência médicaduranteahospitalizac¸ãoinicialparfraturadequadrilpodeserestimadaemcercade US$7.000porpaciente.Asfraturasdofêmursãodolorosaserequeremanalgesiaadequada ime-diata.Otratamentodadorcausadaporfraturasdefêmurédifícilporqueháumnúmerolimitado deanalgésicosdisponíveis,muitosdosquaistêmefeitoscolateraisquepodemlimitaroseuuso. Osopioidessãoosfármacosmaisutilizados,maspodem trazeralgumascomplicac¸ões.Nesse contexto,osbloqueiosdonervofemoralpodemserumaalternativasegura.Éumatécnicade anestesiaregionalespecíficausadapormédicosemmedicinadeemergênciaparaproporcionar anestesiaeanalgesiadomembroafetado.

Objetivo:Compararaeficáciaanalgésicadefentanilversusbloqueiodonervofemoralantes doposicionamentoparrealizarraquianestesiaem pacientescomfraturadefêmuravaliados comescalasdedor.

Métodos: Revisão sistemáticadaliteraturacientífica foi conduzida.Estudos descritos como ensaiosclínicosrandomizadosquecomparambloqueiodonervofemoralefentaniltradicional foramincluídos.Doisautoresdarevisão(MReFH)avaliaramdeformaindependenteosestudos potencialmenteelegíveisparainclusão.Ametodologiadaavaliac¸ãobaseou-senaferramenta desenvolvidapelaColaborac¸ãoCochraneparaavaliac¸ãodeviésdosensaiosclínicos random-izados.AsbasesdedadosdaBibliotecaCochrane,PubMed,MedlineeLilacsforamconsultadas paratodososartigospublicados,semrestric¸õesdelínguaoudetempo.

Resultados: Doisestudosforamincluídosnestarevisão.Obloqueiodonervopareceusermais eficaz quefentanil porviaintravenosa para aprevenc¸ão dadorem pacientescomfratura femoral. Tambémreduziu o uso deanalgesia adicional e diminuiu orisco de complicac¸ões sistêmicas.Obloqueiofemoralreduziuotempodeadministrac¸ãodaraquianestesiaaopaciente asersubmetidoàcirurgiaefacilitouaposic¸ãosentadaparaessefim.

Conclusão:Ousodebloqueiodonervofemoralpodereduzironíveldedoreanecessidadede analgesiaadicional.Hámenoseventosadversossistêmicosassociadosaesseprocedimentoque nãooferecemaioresriscos.Maisestudossãonecessáriosparaconclusõesadicionais.

©2016PublicadoporElsevierEditoraLtda.emnomedeSociedadeBrasileiradeAnestesiologia. Este ´e um artigo Open Access sobuma licenc¸a CC BY-NC-ND(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

Hipfracturesrefertoafractureoccurringbetweentheedge ofthefemoralheadand5cmbelowthelessertrochanter. Thisisoneofthemostcommonorthopaedicemergencies.1,2

of the world.3---5 _{Approximately 77,000 proximal fractures} occur in the United Kingdom each year at an estimated cost of £ _{2 billion.}3,4 _{Nearly 300,000 hip fractures occur} each yearin theUnitedStates.6 _{Theaverage costofcare} during the initial hospitalization for hip fracture is about US$7,000perpatient.6_{AccordingtotheAmericanAcademy} ofOrthopaedicSurgeons,in1988 thecostofhipfractures was$8.7billion,orUS$34,400perpatient.7_{InBrazilthereis} fewdataabouthipfractures.OneresearchconductedinRio deJaneirodemonstratedthathipfracturesmorefrequently impairelderlypeoplebetween80and89years,femaleswith mildsystemicdisease.8_{Onestudyshowsthatthepeak} num-berofhipfracturesoccursbetweentheagesof75and79 yearsinbothmenandwomen,andthenumberofindividuals sufferingtheconsequencesoffractureismuchlargerthan theannualincidencebecausesomefracturesincurdisability foraperiodmuchlongerthan1yearaftertheeven.9

Approximately 98% of hip fractures are managed sur-gically, as fixation provides analgesia and chance of rehabilitation, and reduces the risk of complications.10 Femoralfracturesarepainfulandneedimmediateadequate analgesia.11,12_{At rest,approximatelyone-thirdofpatients} withafracturedhipwillhave mild(orno)pain,one-third will have moderate pain, and one-third will have severe pain.Onmovement,however,overthree-quarterswillhave moderatetoseverepain.10 _{Opiatesandnon-steroidal} anti-inflammatory drugsare thecommonused drugs,but they can bring some complications13 _{and in the elderly this} complications are even more serious because suboptimal metabolism due toloss of hepatic andrenal functions. A femoralnerveblockis aspecificregionalanesthetic tech-nique used by doctorsin emergency medicine toprovide anesthesiaandanalgesiaoftheaffectedleg.14_Itcanreduce pain and opioid requirement in the preoperative period. Theyarealsousedasadjunctstospinalandgeneral anes-thesia,andshouldalwaysbeconsideredwhenthelatteris administered.10

Given theseissues,therelevanceofthisreviewlieson thefactthatashipfracturestendtoincreasewithageing andwealreadyobservethepopulationalageingnewstudies abouttreatmentofsafeandefficacyanalgesiaarerequired.

Objectives

The main goal of this review is tocompare the analgesic efficacyofintravenousfentanylversusfemoralnerveblock beforepositioningtoperformspinalanesthesiainpatients withfemoralfracturesassessedbyPainScales.

Methods

The present study consists of a systematic review of scientificliterature.Studies describedasrandomized con-trolledtrialscomparingfemoralnerveblockandtraditional fentanyl wereincluded. Two reviewers (MR andFH) inde-pendentlyassessed potentiallyeligibletrialsfor inclusion. Disagreements were resolved by discussion with a third reviewer.Wherenecessary,thetrialistswerecontactedfor additionaldataandclarification.The methodology assess-ment was based on the tool developed by the Cochrane Collaboration for assessment of bias for randomized

controlled trials. There were included individuals from allages andeither gender presenting afemoral fracture. TheCochrane Library,PUBMED,MEDLINE andLILACSwere searched for all articles published, without restriction of languageor time. Titles and abstracts were analyzed for MedicalSub Headings (MeSH)terms. The following search termswereused:(‘FEMORALFRACTURES’[MESH]AND ‘FEN-TANYL’[AllFields]AND‘NERVE BLOCK’[AllFields]).When it was necessary, the authors screened citations of the includedstudiesorsearchedinanotherdatabases.

Results

The search was started in August 2014 and completed in November2014.Therewerescreenedatotalof192articles. Howevernot all were suitable for inclusion and only 2 ---accomplishingthecharacteristic mentioned above---were includedinthisreview(Tables1and2).15,16

Discussion

Twosmallstudieswereincluded inthisreview:Sia 200417 realizedthestudy inItalyandIamaroon201018 _conducted the trial in Thailand. Due to some difficulty in blinding research and participants and lack of intention to treat, mosttheypresentsometypeofbiasintheirmethodology. Thismaylimitthequalityoftheevidence.

Undertreated pain can lead to cardiovascular events, delirium; depression, sleep disturbances and decreased responsestointerventionsfor other disease states.19 _Pain canleadtometabolic, endocrineandelectrolyte changes in the body. Moreover, the physiological responses tothe damagecancontributetochronicpersistentpainthatcan occurtimeafter surgery.1 _{Treating painfemoral fractures} isdifficultbecausetherearelimitednumberofanalgesics available,many of which have side effects thatcan limit theiruse.Themanagementofacutepaincombinestheuse of systemic opioids, paracetamol and non-steroidal anti-inflammatorydrugs.1_{Fentanylisalipophilicopioidstronger} than morphine20 _{commonly used in Brazil. It was} devel-oped 40 years ago for parenteral administration because duetoa fastfirst-pass metabolism, oral administrationis notavailable. Fentanylbelongstophenylpiperidine family and is 50---100 times more potent than morphine.21 _After an intravenous bolus, more than80% of the administered dosecan distributefromplasmatohighlyvascular tissues (heart,lung,andbrainlessthan5min).22_InBrazilitis com-monlyusedasanadjuvantdrugusedingeneralanesthesia.15 Amongthe80sitwasstartedtobeusedasanintraoperative analgesicagentwithfewadverseevents.Itcanprovide car-diovascularstabilityeveninillnesspatients,butthereisa directconcentration---effectrelationbetweenthefentanyl andrespiratorydepression. Doseshigherthan2ng/mL are associatedwithclinicallysignificantrespiratorydepression. Thedegreeofrespiratorydepressionisaffectedbythetypes ofsurgicalpopulation,levelofnoxiousstimulation,age,and individualpharmacodynamicresponses.16

Table1 Iamaroon2010.

Methods

Randomizedcontrolledtrial.Patientsallocatedby computer-generatedrandomnumbersintotwogroups. Randomallocationsequenceconcealedinopaque,sealed envelopesuntilagroupwasassigned.

Participants

SirirajHospital,Bangkok,Thailand.

64participants(32=FNB;32=Fentanyl)withfemoral fractures:

Neck:33(FNB:18;Fentanyl:15)

Intertrochanteric:21(FNB:18;Fentanyl:13) Shaft:7(FNB:6;Fentanyl:1)

Distalpartoffemur:3(FNB:0;Fentanyl:3) Age:FNB(65.1±17.5);Fentanyl(68.2±12.4) Sex(male/female):FNB11/20;Fentanyl12/20

Interventions

Femoralnerveblockguidedbyaperipheralnerve stimulatorusing30mLofbupivacaine0.3%(20mLof bupivacaine0.5%and10mLofnormalsaline0.9%)versus 2dosesofIVfentanyl0.5␮gwitha5mininterval

betweenthedoses.

Outcomes

Follow-up:fromDecember2006toMay2008.

Painscores15minafteranalgesiaassessedbyanumeric ratingpainscale(FNB:2.7±2.6;fentanyl:3.3±2.7);

p=0.37

Painscoresduringpositioningforspinalanesthesia(FNB: 6.1±2.6;Fentanyl:5.9±3.4);p=0.8

Additionalfentanylrequirement(FNB:19.5±16.4; Fentanyl:17.1±18.4);p=0.59

Satisfactionofpatientposition(FNB:yes=28;no=4; Fentanyl:yes=26;no=6);p=0.49

Timetoperformspinalanesthesia(FNB:7.0±4.2; Fentanyl:6.6±4.3);p=0.74

Notes

Assessorsofpainwereblindedtothepatient’sallocated treatmentgroup.

RiskofBias

Performancebias---patientswereawareoftheir treatmentgroup.

injectinglocalanestheticclosetothenerve;usingablind methodnamedfasciailiacablockthatuseslargeamountsof anesthetic;usinganotherblindmethodnamedThreeinOne Blockinaparavascularapproachthatcanblockthefemoral, obturatorandlateralcutaneousnerveswithasingle injec-tion;orusinganultrasoundguidancetoidentifythefemoral nerve.24 _{One surveyconductedin England concludedthat} femoralnerveblocksareanunderutilizedeffectivemethod ofanalgesiafor patients withafemoral fractureandit is associatedwithalowriskofcompartmentsyndrome.25

Itissaidthattheuseoffemoralnerveblocksbringsalow riskofadverseevents,withthemostlikelybeingvascular haematoma, nerve damage, infection and intravascular infection.1_{Twootherreviewsconcludedthatnerveblockade} seemed tobe more effective than opioids alone for

pre-Table2 Sia2004.

Methods

Randomizedcontrolledtrial.Thepatientswererandomly dividedintotwogroups:FNB(femoralnerveblock)and IVA(IVanalgesia).

Participants

AziendaOspedalieraCareggi,Firenze,Italy. Twentypatientspresentingfemoralshaftfractures. Age:FNB(35±11);IVA(32±9).

Sex(male/female):FNB7/3;IVA6/4.

Interventions

Femoralnerveblockguidedbyaperipheralnerve stimulatorusing15mLoflidocaine1.5versusonedoseof IVfentanyl3␮g/kg.

Outcomes

Follow-up:fromSeptember2002toNovember2003. VisualAnaloguePainScoresatpositioningforspinal anesthesia5minafterinterventions:FNB=0.5±0.5; IVA=3.3±1.4;p<0.001

Timetoperformspinalanesthesiaafterintervention (min):FNB=1.8±0.7;IVA=3.0±1.1;p<0.05 Qualityofpatientposition(0to3):FNB=2.8±0.4; IVA=1.6±0.7;p<0.005

Patientacceptance(yes/no);FNB=10/0;IVA=6/4.

Notes RiskofBias

Riskofselectionbias---theauthordoesnotmentionthe randomizationcriterianortheallocationconcealment.

ventingpaininpatientssufferingfromafemoralfracture. Thiswasshowedbycomparingscoresassessedbydifferent recognized scales which measures pain before and after the procedure.13,26 _{Previous studies have demonstrated} the efficacy of nerve blocks.27,28 _{Although Iamaroon}18 _did notreportstatisticallysignificantanalgesiceffectbetween femoralnerveblockandintravenousfentanyl,Sia17_showed thatthescoresofpainatpositioningforspinalanesthesia and the time required to performspinal anesthesia were lowerinthegroupthatreceivedfemoralnerveblock.The qualityofpatientpositionandthepatientacceptancewere higherinthegroupsubmittedtothefemoralnerveblock. May be the inconclusiveeffects of Iamaroon weredue to suboptimaldoseoflocalanesthetic.

Berry23_{in1997statedthatthefemoralnerveblock} pro-videsalmosttotalpainreliefandabolitionofmusclespasm withinafewminutes;thereisnegligiblesystemicreaction totheblockprocedure;painduringprocedureswhichoften necessitatepatientmovementcanbeprevented.

Conclusions

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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