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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 4  |  Page : 378-384

Efficacy of ultrasound-guided fascia iliaca compartment block with ropivacaine and dexmedetomidine for postoperative analgesia in hip arthroplasty


Department of Anaesthesia and Intensive Care, Faculty of Medicine, Al Azhar University, Cairo, Egypt

Date of Submission02-Aug-2019
Date of Decision17-Oct-2019
Date of Acceptance17-Nov-2019
Date of Web Publication14-Feb-2020

Correspondence Address:
Mostafa M Sabra
Ain Shams Al-Gharbia, Almashroae Street, Arafa Tower, 12273
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_101_19

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  Abstract 


Background Suprainguinal fascia iliaca block (FICB) has been reported to provide effective postoperative analgesia in patients with femur fracture. This study aimed to evaluate the effectiveness of FICB with ropivacaine and dexmedetomidine for postoperative analgesia in hip arthroplasty.
Patients and methods This prospective, double-blinded, randomized, controlled, clinical study was conducted on 57 patients with American Society of Anesthesiology physical status I–II, aged 50–70 years, undergoing elective hip arthroplasty. Subarachnoid block was given at the L3-4 interspace, and then the patients were divided into three groups according to the drug given in the suprainguinal fascia iliaca after subarachnoid block and before skin incision: group C received 40 ml normal saline, group R received 40 ml ropivacaine 0.2%, and group D received a mixture of dexmedetomidine 2 μg/kg diluted in 0.2% ropivacaine with 40 ml total volume. The primary outcome was evaluation of postoperative analgesia using numerical rating scale, recorded at 30 min and at 1, 3, 6, 9, 12, 15, 18, 21, and 24 h. Analgesic consumption and first analgesic request were the secondary outcomes.
Results Numerical rating scale scores were significantly higher in group C when compared with groups R and D, at the 1, 3, and 6h. Postoperative pethidine consumption during the first 24 h was found to be significantly less in group R and group D when compared with group C. There was a statistically significant difference in the group D when compared with group C and group R, with less number of patients who required rescue analgesic in 24 h and prolonged time for first request of rescue analgesic.
Conclusion Addition of dexmedetomidine to ropivacaine in FICB was efficacious in decreasing severity of pain, decreasing total analgesic consumption during the first 24 h, and prolonging the time for first request of analgesia in the postoperative period for patients undergoing hip arthroplasty.

Keywords: dexmedetomidine, hip arthroplasty, postoperative analgesia, ropivacaine, suprainguinal fascia iliaca block


How to cite this article:
Sabra MM, Abdalla M, Abdelrahman AS. Efficacy of ultrasound-guided fascia iliaca compartment block with ropivacaine and dexmedetomidine for postoperative analgesia in hip arthroplasty. Al-Azhar Assiut Med J 2019;17:378-84

How to cite this URL:
Sabra MM, Abdalla M, Abdelrahman AS. Efficacy of ultrasound-guided fascia iliaca compartment block with ropivacaine and dexmedetomidine for postoperative analgesia in hip arthroplasty. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jul 16];17:378-84. Available from: http://www.azmj.eg.net/text.asp?2019/17/4/378/278390




  Introduction Top


The lumbar plexus could be approached in an anterior manner through the suprainguinal fascia iliaca compartment block. It is a technique that blocks three nerves similar to a 3-in-1 nerve block. The fascia iliaca space is the space between iliopsoas muscle behind and the fascia iliaca in front. The femoral nerve, the lateral cutaneous nerve, and the obturator nerve are located below the fascia iliaca at the pelvic area [1]. Fascia iliaca block (FICB) is widely used in lower extremity surgery and provides effective postoperative analgesia with relatively few adverse effects [2]. The success rate of the pop method ranged between 35 and 47%, which was considered low [1],[3]; nevertheless, higher rate of success (82–87%) and in a relatively quick fashion were attributed to performing it in real-time ultrasonic guidance [3],[4],[5]. Findings from some studies showed that suprainguinal FICB alongside total hip arthroplasty among patients with femur fracture led to analgesic effects. Patients with acute hip fracture (n=48) were subjected to suprainguinal FICB through a double-blind randomized study conducted by Foss et al. [6]. In the FICB group, the patients received an FICB with 1.0% mepivacaine and a placebo intramuscular injection of isotonic saline, and in the morphine group, the patients received a placebo FICB with 0.9% saline and an intramuscular injection of 0.1 mg/kg morphine. The group with suprainguinal FICB experienced optimum pain relief. It was concluded that not only is the integration of suprainguinal FICB and total hip arthroplasty easily learned and effective procedure, but it also decreased the consumption of opioids. Besides, patients with femur fractures experienced reduced consumption of opioids and the rate of preoperative pain when suprainguinal FICB is used alongside total hip arthroplasty as reported in some studies [7],[8],[9]. Nevertheless, there were differences for postoperative pain between femur fracture and total hip arthroplasty, as the tissue trauma site and degree differed significantly among neck femur fracture and hip surgery patients. Although few randomized studies regarding total hip arthroplasty with suprainguinal FICB exist, there is little knowledge on the effectiveness of suprainguinal FICB for postoperative pain control in total hip arthroplasty [10],[11],[12].

Dexmedetomidine, an α2 adrenergic receptor agonist, exerts its analgesic and sedative effects through its α2 receptor affinity [13]. Li et al. [14] suggested that dexmedetomidine can increase the efficacy and prolong the duration of ropivacaine blockade.

This study sought to determine the effectiveness of postoperative analgesia with suprainguinal FICB alongside ultrasonic guidance using mixtures of ropivacaine, dexmedetomidine, and ropivacaine, with postoperative analgesia following hip arthroplasty as the primary outcome, whereas secondary outcomes included hemodynamic changes, quantity of patients who needed analgesic assistance within 1 day, duration for initial analgesic request, and consumption of pethidine (analgesic).


  Patients and methods Top


After Local Ethics and Research Committee approval and written informed consents from the patients, this prospective, randomized, double-blinded, clinical study was conducted at Al-Hussein University Hospital. A total of 57 adult patients scheduled for hip surgery consented to participate in the study. Inclusion criteria were patients undergoing hip surgery more for than 1 h duration, under subarachnoid anesthesia, aged between 50 and 70, years, with the American Society of Anesthesiology physical status classification score (ASA) I–II.

Exclusion criteria were as follows: refusal at enrolment, known solid organ diseases, bleeding diathesis, drug abuse, received an opioid analgesic prescription taken within a 24 h period before the operation, and psychiatric disorders. CONSORT checklist was used for enrolment and allocation of patients and is shown in [Figure 1].
Figure 1 CONSORT diagram of study.

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Preanesthetic visit included thorough evaluation of the patients a day before the scheduled operation. Anesthesia administration was performed similarly for all groups utilizing a standard protocol. Patients were premedicated with IV midazolam (0.05 mg/kg for lean body weight) in the preoperative holding area, and then transferred to the operating room. Patients were preloaded with Ringer’s solution at 15 ml/kg, 30–60 min before intrathecal drug administration.

In operating room, standard monitoring included five-lead ECG, heart rate (HR), arterial oxygen saturation (SpO2,) measured by pulse oximeter, and noninvasive blood pressure measurements, and baseline vital signs were then recorded. Patients were positioned in the sitting position, supported, and chin-flexed on the chest; those who were unable to sit were positioned in the lateral decubitus position.

The back was prepared using povidone iodine, and the area was draped with a sterile towel. Lumbar puncture was performed through the L3–L4 interspace using midline approach, and 2.5 ml of 0.5% bupivacaine was injected.

Ultrasound-guided blocks

All blocks were performed immediately after subarachnoid anesthesia, under sterile conditions, before the beginning of the surgical procedure. In the supine position, the inguinal crease area was sterilized with betadine. After putting a 5 to 12 MHz linear probe (SonoSite M-Turbo, Fujifilm SonoSite, Inc., Bothell, Washingtton, USA) parallel to the inguinal ligament on the inguinal crease, we found the femoral artery, fascia lata, fascia iliaca, iliacus muscle, and femoral nerve. From this view, after rotating the probe 90–135° counter clockwise, we made the probe parallel to the vertebrae axis. Using the out‑plane technique, a 22 G/80 mm insulated echogenic block needle, attached to an intravenous extension tube between the needle and the syringe, was inserted along the plane and advanced toward the fascia iliaca and iliacus muscle. When the needle was advanced, the heel-toe maneuver was used for needle visualization. After confirming the passage of the needle through the fascia iliaca using fascial click and 2 ml of saline, after injecting the normal saline, we used a hydrodissection technique under real-time ultrasound guidance. In the hydrodissection technique, a small amount of local anesthetic was injected (1–2 ml), and then, the needle was advanced to the proximal side for the proximal spreading of the local anesthetic. Through this hydrodissection, the needle is passed proximally, deep through the fascia iliaca and into the iliac fossa, moving only into the space created by fluid collection. The hydrodissection was repeated until the whole needle was inserted into the skin, with total volume of 40 ml.

A total of 57 patients were enrolled, and three groups were present in the study according to drug mixture given: group C (n=19) (as control group) was injected with 40 ml normal saline; group R (n=19) with 40 ml ropivacaine 0.2%, with total volume of 40 ml; and group D (n=20) received mixture of dexmedetomidine 2 μg/kg diluted in ropivacaine 0.2% (total volume of 40 ml).

Patients were assigned a random identification number before surgery, and all data were collected using this identification number. Group assignments were done using simple randomization using the sealed envelope technique, and all data were collected blindly. Blocks were performed by anesthesiologist who did not perform any role in data collection or analysis.

The numerical rating scale (NRS) was used to evaluate severity of postoperative pain; it is a segmented numeric version of the visual analog scale in which a patient selects a whole number (0–10), ranging from ‘0’, representing ‘no pain’, to ‘10’, representing ‘pain as bad as you can imagine’ or ‘worst pain imaginable’. It is considered a unidimensional pain intensity measurement in adults.

Pain score was estimated at the following intervals: at 30 min, and 1, 3, 6, 9, 12, 15, 18, 21, and 24 h at rest. If the pain score was greater than 4, intravenous pethidine 50–100 mg was given. For study groups, the total amounts of pethidine, during the 24 h after surgery were calculated, and the first request to analgesia is recorded.

Hemodynamic parameters (HR and mean arterial pressure) were recorded before suprainguinal FICB was performed, and then at 2, 4, 8, 12, 18, and 24 h postoperatively.

Primary outcome measure was postoperative analgesia using NRS pain score at 30th min, and at 1, 3, 6, 9, 12, 15, 18, 21, and 24 h at rest. Secondary outcomes were analgesic consumption (pethidine), number of patients who required rescue analgesic in the first 24 h, time for first analgesic request, and hemodynamic changes.

Sample size calculation

We expected the perioperative analgesia effect to decrease after 3 h; at this time, the effect of the block would be more noticeable. We considered a reduction of the NRS score by at least 2 after 3 h to be significant, with SD of 1.76, when compared with the control group. Sample size calculation with a power of 80% (1–β), at 5% significance level (α), and the effect size of 0.5 with three groups for analysis of variance revealed a sample size for each group of 18 patients. Considering these calculations and dropouts, the study was designed to have at least 19 patients in each group.

Statistical analysis

SPSS 16.0 Statistical package program (SPSS; SPSS Inc., Chicago, Illinois, USA) was used for statistical analysis. Descriptive statistics were expressed as mean±SD, median and interquartile range, or number. Analysis of variance test was used for parametric variables. For data without normal distribution and nonparametric variables, Kruskal–Wallis test was performed. Categorical variables or ratios were compared using χ2-test. P less than 0.05 was considered statistically significant.


  Results Top


Hip surgery was performed in 63 patients with American Society of Anesthesiology physical status classification score I–II; four patients were excluded as they did not meet inclusion criteria, and one patient declined to participate. Therefore, 58 patients were selected in this study. Age and sex distributions and type and duration of surgery are shown in [Table 1]. There were no statistically significant differences regarding these parameters. All procedures were completed uneventfully, and no complications owing to suprainguinal FICB or subarachnoid anesthesia were observed.
Table 1 Demographics and surgical information of study patients, according to groups

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Regarding NRS scores, there were statistically significantly higher scores in the group C when compared with groups R and D, at the first, third, and sixth hours. At these times, there was a statistically significant difference between group C and two other groups (comparison between group C vs group R and group C vs group D at first hour, P<0.001; at third hour, P<0.001; and at sixth hour, P=0.001, respectively). No difference was found between group R and group D (P>0.05). NRS scores at different times are shown in [Table 2].
Table 2 Postoperative pain scores (numerical rating scale score)

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Regarding pethidine consumption, in post hoc analyses, the first 12 h as well as the total pethidine consumption was similar between group R and group D (P>0.05), but significantly higher in group C when compared with both groups (comparison between group C vs group R and group C vs group D at first 12 h P<0.001 and P<0.001, and at first 24 h, P<0.001 and <0.001, respectively).

Regarding the number of patients requiring rescue analgesic in the first 24 h were 19, 14, and 7 for group C, group R and group D, respectively, which showed a statistically significant difference (P<0.05) between group D and the other two groups with less number of patients requiring rescue analgesia. Regarding the time for first analgesic request, it was significantly delayed in the group D (573.33±95.10 min) compared with the group C (242.82±48.34 min) and group R (381.91±65.10 min) (P=0.013) ([Table 3]).
Table 3 Pethidine consumption, rescue analgesic required patients, and first analgesic request according to groups

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Regarding the mean arterial pressure and HR, there were no statistically significant differences in the first 24 h postoperatively ([Figure 2] and [Figure 3]).
Figure 2 Comparison of mean arterial pressure between three groups.

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Figure 3 Comparison of heart rate between three groups.

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  Discussion Top


The objective of the study was to determine the effectiveness of suprainguinal FICB postoperative analgesia alongside ultrasonic guidance using mixtures of ropivacaine dexmedetomidine and ropivacaine, with the primary outcome being the postoperative analgesia following hip arthroplasty, whereas secondary outcomes included hemodynamic changes, quantity of patients who needed analgesic assistance within 1 day, duration for initial analgesic request, and consumption of pethidine (analgesic).

General patient satisfaction, enhanced functional recovery, earlier ambulation, and commencement of physical therapy are some of the benefits of post-operative pain control. Additionally, the risk of adverse incidences such as deep vein thrombus and reduction of hospitalization can be achieved through optimum management of pain [15]. The opioid adverse effects that patients experience, including, retention, respiratory depression, pruritus, vomiting, sedation, constipation, altered mental status, and an increased incidence of falls, are minimized when the necessity for postoperative opioid is reduced through regional anesthesia use [16].

In view of this, hip surgery postoperative analgesia could be undertaken effectively using lumbar plexus regional blocking methods, including 3-in-1 block, psoas compartment block, and suprainguinal FICB. Of the aforementioned methods, the suprainguinal FICB emerges as the easily accessed and performed approach wherein lumbar plexus can be blocked.

Hip arthroplasty pain can be relieved effectively when using lumbar plexus block, quadratus lumborum block, femoral nerve block, and fascia iliaca compartment block [17],[18].

The study exploring total hip arthroplasty reported that combining ropivacaine and dexmedetomidine significantly decreased analgesic requirement in the initial 24 h and pain levels in the initial hours of post-operation as opposed to solely using an injection regimen of ropivacaine. The fact that all injections were undertaken subarachnoid anesthesia implied that the time for analgesia onset could not be computed in the study. As an imaging study of LA extension to lumbar plexus demonstrated, the possibility for complications, such as formation of hematoma within USG, might be reduced [19]. Mechanical damage of the nerves is reduced significantly because total hip arthroplasty does not involve direct contact. Nevertheless, there were no failures for the groups that were investigated.

Past studies indicate that suprainguinal FICB produces analgesic effects after hip surgery, which is consistent with the conclusion drawn from our study. A total of 50 patients on hip arthroplasty were subjected to ultrasound-guided block within the fascia iliaca plane using 50 μg dexmedetomidine and 30 ml ropivacaine for patients with more than 50 kg, whereas fascia iliaca compartment block emerged as an essential instrument within multimodal analgesic care, with decreased total consumption of opioid postoperatively, whereas total duration increased by 18–24.3 h with dexmedetomidine use characterized by minimal sedation and hemodynamic instability [20].Additionally, Krych et al [21] found that hip surgery patients experienced high overall satisfaction, high quality pain relief, and reduced consumption of opioids when using suprainguinal FICB. Nevertheless, Shariat et al [12] did not report any significant variation in the rate of postoperative pain and 24 h consumption of opioids among 32 patients between suprainguinal FICB using 0.5% (30 ml) ropivacaine and similar block with 0.9% (30 ml) normal saline in THA.

Meanwhile, during intraoperative and postoperative hip arthroplasty, suprainguinal FICB provides a period without pain and generates negligible hemodynamic differences.

The patients in the current study did not exhibit respiratory depression, pruritus, nausea, and vomiting. The lack of effects linked to respiratory depressant makes ropivacaine dexmedetomidine beneficial and successful as opposed to other opioids. Li et al. [14] and Sivakumar et al. [22] also used dexmedetomidine as an adjuvant to LA with good results.

Based on our orthopedists’ observation in the initial 24 h after operation, the hip prosthesis immobility prevented the assessment of the NRS score within passive motion of the hip joint.


  Conclusion Top


Addition of dexmedetomidine to ropivacaine provides longer duration and good quality postoperative analgesia and reduced requirement for rescue analgesic in comparison with ropivacaine alone in suprainguinal FICB in the postoperative period in hip arthroplasty.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interst.



 
  References Top

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