Peripheral Nerve Block vs Spinal Anesthesia in Patients With Femur Fracture

Study Overview
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Brief Summary
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Femur Fractures (PF) are nowadays one of the main social and health problems in industrialized countries. PF are defined as crack or break of the proximal femur and they represent an important cause of morbidity and mortality in elderly population. The main prospective and retrospective studies do not show the superiority of subarachnoid anesthesia over general anesthesia in terms of 30-day mortality and post-operative complications, however they always recommend the execution of PeripheralNerve Blocks (PNB). Loco-regional anesthesia plays a fundamental role in the treatment of peri-operative pain assuring better hemodynamic stability and has already fully entered national and international pain management protocols, because it allows faster recovery times with a reduction in the use of intravenous analgesic drugs in particular opioids and consequently a faster discharge and a reduction in peri-operative complications and the costs of assistance. The aim of our study will be to propose an anesthetic approach based on PNB that could be particularly suitable for frail patients especially when Neuroaxial Anesthesia (NA) is not feasible due to difficulty to position the patient or to the withdrawal time of anticoagulant or antiplatelet therapies.

Detailed Description
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A venous access (16-18 G) will be placed in the operating room and antibiotic prophylaxis will be administered (Cefazolin 1 or 2 gr. iv or, in case of allergy, Clindamycin 600 mg iv). Pantoprazole 40 mg iv will also be administered. Pulse oximetry (SpO2), heart rate (HR), body temperature (C°), continuous invasive blood pressure (cIBP), brain oximetry with ForeSight will be monitored. A co-loading with 500 ml of intravenous crystalloids will be done and ondansetron 4 mg will be administered intravenously; pre-procedural sedation will be performed with Midazolam 0.01-0.03 mg/Kg. All patients in both groups will receive intraoperative sedation with Dexmedetomidine 0.4-0.7 gamma/Kg/h and o2-therapy with a nasal cannula with a flow rate of 2L/min. At this point, the type of anesthesia will be followed on the basis of the randomization group.The following variables will be evaluated: Postoperative pain evaluated by VAS and PAINAD scales time to motor block regression (duration of motor block) rate of side effects (nausea, vomiting and delirum) rescue dose analgesics needed (interval between anesthesia and first rescue dose) surgical compliance (obtained with a 5-point Likert scale score filled out by the surgeon) duration of surgery

Official Title
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Peripheral Nerve Block vs Spinal Anesthesia in Patients With Femur Fracture: A Prospective Randomized Controlled Study

Conditions
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Femur Fracture, Peripheral Nerve Block, Spinal Anesthesia

Intervention / Treatment
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* Procedure: Spinal anesthesia
* Procedure: Peripheral nerve blocks
* Drug: Anesthesiological mixtures (Spinal anesthesia)
* Drug: Anesthesiological mixtures (Peripheral nerve block)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria : Subject has signed and dated an Informed Consent Form Subject is classified as a ASA (American Society of Anesthesiologists) status I-IV Subject is age over 65 years old Subjects with femur fracture, candidates for intramedullary nailing surgery, to be operated on within 48 hoursPatients undergoing total hip arthroplasty Exclusion Criteria: Age younger than 65 years Subject with contraindications to subarachnoid technique or peripherical nerve blocks Subject with local anesthetic allergy Subject in whom the treatment protocol could not be fully applied were excluded from this study. Study refusal Neurological disease of the lower limbs

Ages Eligible for Study
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Minimum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Spinal Anesthesia<br>The participant will receive a spinal anesthesia. | Procedure: Spinal anesthesia<br>* Spinal anesthesia will be performed at the L2-L3 or L3-L4 interspace with the patients in the lateral position with the fractured side up. A small dose of local anesthetic will be injected into the skin at the planned site of insertion. More local anesthetic will be then administered along the intended path of the spinal needle insertion to the estimated depth of the supraspinous ligament. This serves a dual purpose: additional anesthesia for the spinal needle insertion and identification of the correct path for spinal needle placement. The technique will be performed aseptically in the subarachnoid space after observing clear Cephalo-Spinal Fluid (CSF) in the spinal needle 25 Gauge, and without releasing the CSF. Selected patients will be received Hypobaric Bupivacaine 0.5% 10 mg and Sufentanil 5 µg and will be maintained the lateral position for 15 min. At the end of these they will be gently placed in supine position.<br>Drug: Anesthesiological mixtures (Spinal anesthesia)<br>* The anesthesia mixtures were injected into the subarachnoid space for spinal anesthesia. It consisted of the following local anesthetics and adjuvants: Hypobaric Bupivacaine 0.5% 10 mg and Sufentanil 5 µg.<br>|
| Active Comparator: Peripheral nerve block<br>The participant will receive a combination of femoral nerve block, sciatic nerve block with parasacral approach, lateral femoral cutaneous nerve block and obturator nerve block. | Procedure: Peripheral nerve blocks<br>* In this group, four nerve blocks will be associated to ensure adequate anesthesia and analgesia during surgery. Sciatic nerve blocks with para sacral approach will be performed with a needle connected to an electrical nerve stimulation. The needle will be advanced until contraction of the related muscles. Next, an anesthetic solution of Ropivacaine 0.375% (dose 37.5 mg) plus Mepivacaine 1% (dose 100 mg) and Dexamethasone 4mg, total volume 21 ml, will be injected. Lateral femoral cutaneous, femoral and obturator nerve blocks, femoral will be performed with the ultrasound technique. After identifying the nerves, a needle will be inserted with an in plane approach and will be injected. The anesthesia mixture will consist for all of :Ropivacaine 0.375% (dose 9.375 mg) plus Mepivacaine 1% (dose 25 mg). The volumes of the 3 anesthesia mixtures will be respectively: 1ml, 15ml,5ml.<br>Drug: Anesthesiological mixtures (Peripheral nerve block)<br>* The anesthesia mixtures were injected into selected peripheral nerves . It consisted of the following local anesthetics and adjuvants: Ropivacaine 0.375% plus Mepivacaine 1% and Dexamethasone 4 mg.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Postoperative pain evaluated by VAS scales | The VAS assessment will be done with a 10-cm-long line with verbal anchors at both ends (no pain on the far left and the most intense pain on the far right). The patient will mark a dot on the line corresponding to the pain intensity rating. | Every 6 hours during treatment until the first 24 postoperative hours | 
| Postoperative pain evaluated by PAINAD scales | The PAINED scale (Pain Assessment in Advanced Dementia Scale) assesses 5 items: facial expression, breathing, negative vocalizations, consolability and body language with a range from 0 to 10 (1-3=mild pain; 4-6=moderate pain; 7-10=severe pain). | Every 6 hours during treatment until the first 24 postoperative hours | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of postoperative nausea and vomiting (PONV) | We will analyze the risk factors of postoperative nausea and vomiting (PONV) by administering an Apfel score to each patient, practicing intraoperative and postoperative antiemetic treatment in accordance with the 2020 Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. | Every 6 hours during treatment until the first 24 postoperative hours | 
| rescue dose analgesics needed | interval between anesthesia and first rescue dose.Pharmacological therapy will be based on the patients' responses. After surgery, we will administer intravenous paracetamol 1 g 3 times a day. Ketorolac 30 mg (not for glomerular filtration rate < 50 ml/min) or Oxycodone (up to 0.1mg/Kg) mg will be available as rescue dose. Pain control will be considered good in case of VAS and PAINED score less than or equal to 4. | From the end of treatment to 24 hours postoperatively | 
| surgical compliance | will be obtained with a 5-point Likert scale score filled out by the surgeon. | 1 hours after surgery | 
| The duration of surgery (min) | The duration of surgery (min), assessed as Planned time(min) and Effective time(min) | 4 hours after skin incision | 
| Rate of Delirium | Postoperative delirium (POD) is an acute and fluctuating alteration of mental state of reduced awareness and disturbance of attention, which begins in the recovery room and occurs up to 5 days after surgery. POD will be detected by 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) and has four features: (1) altered mental status/fluctuating course, (2) inattention, (3) altered level of consciousness, and (4) disorganized thinking [27]. For the prevention and treatment of POD, we will follow the 2017 European Society of Anesthesiology guidelines. | Every 6 hours during treatment until the first 24 postoperative hours | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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SPINAL ANESTHESIA, FEMUR FRACTURE, NERVE BLOCK, LOCOREGIONAL ANESTHESIA