A comparative study on combined general anesthesia with either continuous fascia iliaca block or epidural anesthesia in patients undergoing lower limb orthopedic surgeries :Nihal G.E. Nooh, Ahmed M.S. Hamed, Aasem A Moharam, Ahmed M Rashad, Ain-Shams Journal of Anaesthesiology

ORIGINAL ARTICLE
Year : 2016 | Volume : 9 | Issue : 1 | Page : 76--82

A comparative study on combined general anesthesia with either continuous fascia iliaca block or epidural anesthesia in patients undergoing lower limb orthopedic surgeries

Nihal G.E. Nooh, Ahmed M.S. Hamed, Aasem A Moharam, Ahmed M Rashad
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, Cairo, Egypt

Correspondence Address:
Ahmed M.S. Hamed
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, 11471 Cairo
Egypt

Abstract

Introduction The purpose of this study was to compare between epidural anesthesia and continuous fascia iliaca block in adults patients undergoing fixation of neck femur or knee arthroplasty including comparison of analgesic efficacy, side effects, and complications. Patients and methods The study was performed upon 60 patients, aged 20-60 years, and randomly distributed among two groups. Group A included 30 patients who received lumber epidural anesthesia, using Tuohy needle 18 G and epidural catheter 20 G, injected initially with 15 ml bupivacaine HCl 0.25% then 6-8 ml/h bupivacaine HCl 0.125% as continuous epidural infusion for 12 h postoperatively. Group B included 30 patients who received fascia iliaca block using Tuohy needle 18 G, injected initially with 20 ml bupivacaine HCl 0.25%, then an epidural catheter 20 G was threaded through the needle and another 20 ml of local anesthetic was injected, followed by 8-10 ml/h bupivacaine HCl 0.125% injected as continuous epidural infusion into the plane for 12 h postoperatively. Results Regarding the technique time, the fascia iliaca group B was significantly faster than the epidural group A. The results showed that performing continuous fascia iliaca block was a significantly faster technique, providing fewer complications such as hypotension, postoperative vomiting, and urinary retention and more patient satisfaction in comparison with epidural anesthesia. Conclusion Continuous fascia iliaca block provided effective unilateral analgesia in patients undergoing fixation of fractured femur neck or shaft or knee arthroplasty with a high patient satisfaction rate, low incidence of hemodynamic instability, and low incidence rate of complications when compared with epidural analgesia.

How to cite this article:
Nooh NG, Hamed AM, Moharam AA, Rashad AM. A comparative study on combined general anesthesia with either continuous fascia iliaca block or epidural anesthesia in patients undergoing lower limb orthopedic surgeries .Ain-Shams J Anaesthesiol 2016;9:76-82

How to cite this URL:
Nooh NG, Hamed AM, Moharam AA, Rashad AM. A comparative study on combined general anesthesia with either continuous fascia iliaca block or epidural anesthesia in patients undergoing lower limb orthopedic surgeries . Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2023 Sep 29 ];9:76-82
Available from: http://www.asja.eg.net/text.asp?2016/9/1/76/178884

Full Text

Introduction

Lower limb surgery is often painful and requires aggressive management. Poorly treated pain can have negative impact on recovery, especially owing to disruption in physiotherapy resulting in stiffness of joints and slow progress in mobility [1] .

Although different techniques are used, the best technique based on efficacy and safety has not been determined. General anesthesia, neuroaxial blockades, and peripheral nerve blocks (PNBs) represent the techniques used more often [2] .

Each technique has different efficacy with advantages and disadvantages. Neuroaxial blocks are probably used more often due to the quality and predictability of the anesthetic blockade, low cost, and easiness to perform. However, those techniques are not devoid of risks [3] .

Recently, lumbar plexus blocks for anesthesia and analgesia have received more attention. Excellent analgesia and limited motor and sympathetic blockades, without the adverse effects of local anesthetics and opioids administered in the neuroaxis, represent the main advantages of PNB [4] .

Fascia iliaca compartment block is a modification of the 'three-in-one' femoral block described by Winnie et al. [5] .

This duration of analgesia is insufficient in most cases, leading to the need for other techniques that provide prolonged analgesia. Continuous peripheral block techniques can extend block duration and have been widely used in adults [6] .

Continuous fascia iliaca compartment block represents an alternative to continuous femoral nerve block (CFNB), and the addition of lateral cutaneous and obturator nerve blocks to the femoral nerve block may be helpful for pain control in the thigh or in the anterior and medial aspect of the knee [7] .

The purpose of this study was to compare between epidural anesthesia and continuous fascia iliaca block in adult patients undergoing fixation of femur fractures or knee arthroplasty, including comparison of analgesic efficacy, side effects, and complications.

Patients and methods

Sixty patients presenting to Ain-Shams University hospitals for lower limb surgeries were enrolled in this experimental study after providing written consents. Approval was obtained from the Research Ethics Committee of Anesthesia and Intensive Care Department, Ain-Shams University for a single-center comparative randomized study.

Patients included in the study had age range between 30 and 70 years, were undergoing lower limb orthopedic surgeries, ASA I and ASA II, and had normal coagulation profile. Patients were excluded from the random distribution, if they refused to participate in the study, had peripheral neuropathies, coagulopathies, hypersensitivity to drugs used for analgesia, noneffective blocks, infection at the site of puncture, and spinal deformities or history of spinal surgery.

In this study, all patients underwent preoperative assessment for evaluation of the patient's medical status. On arrival to the operating room, standard monitoring including ECG, noninvasive blood pressure (BP) measurement, and pulse oximetry was connected. Baseline hemodynamic readings were recorded before initiating the technique. Once intravenous access by a wide-bore cannula had been achieved, infusion of warmed crystalloid solution was initiated at a rate of 15 ml/kg/h.

Total sample calculated was 60 patients divided and assigned randomly into two equal groups (1 : 1). All anesthetic blocks were performed by the same anesthesiologist and followed by general anesthesia for all patients. In group A (n = 30), epidural catheter 20 G (Perifix; B. Braun, Melsungen, Germany ) was inserted under complete aseptic conditions into the epidural space at the L3-L4 or L4-L5 interspace using loss-of-resistance technique by an 18 G Tuohy needle. After 5 min of injection of 4 ml lidocaine 2% with epinephrine 1 : 200 000 (5 mcg/ml) as a test dose into the epidural space, 15 ml of bupivacaine HCl 0.25% was injected as initial volume. After initial injection, 6-8 ml/h bupivacaine HCl 0.125% was injected as continuous infusion through the epidural catheter throughout the operation and for 12 h postoperatively. After 12 h, 6 ml bupivacaine HCl 0.125% was injected through the epidural catheter before its extraction. In group B (n = 30), under complete aseptic condition and local anesthesia, 1 cm caudal to inguinal ligament along lateral third of a line joining iliac crest and symphysis pubis 2 cm lateral to femoral pulse, 18 G Tuohy needle was inserted at a right angle to skin; after piercing the skin, the needle angle was adjusted to about 60° directed cranially. The needle was advanced through two distinct 'pops' then the angle was reduced between needle and skin surface to about 30°, and the needle was advanced further 1-2 mm. After aspiration, 20 ml bupivacaine HCl 0.25% was injected. After the sheath has been distended, epidural catheter 20 G (Perifix; B. Braun) was inserted through the Tuohy needle. Another 20 ml of the local anesthetic solution was administered over 1-min period with firm pressure applied manually just distal to the puncture site. After injection, 8-10 ml/h bupivacaine HCl 0.125% was injected as continuous infusion through the epidural catheter into the plane throughout the operation and for 12 h postoperatively.

Both groups received general anesthesia induced with 0.5 µg/kg of fentanyl, 2 mg/kg of propofol, and 0.5 mg/kg of atracurium. After tracheal intubation, general anesthesia was maintained with sevoflurane in a 1 : 1 mixture with oxygen and air under controlled mechanical ventilation; atracurium 0.3 mg/kg/h and ventilator parameters were adjusted to maintain normocapnia (35-45 mmHg).

BP both systolic and diastolic and heart rate (HR) were recorded upon arrival of the patient to the anesthetic induction room immediately before the blockade and skin incision at the beginning of the procedure and 1 min after skin incision, then every 10 min until the end of the surgery. Hypotension (systolic BP < 100 mmHg or a decrease of more than 30% from baseline) was treated with intravenous fluids ± intravenous ephedrine 15 mg if needed. Crystalloids and colloids were used for fasting replacement, hourly fluid needs, and replacement of blood loss. Hemodynamic effects secondary to the blockade were evaluated by the variation in the levels of mean arterial BP and HR and by the mean dose of ephedrine administered from the execution of the blockade until the end of the surgery. The efficacy of the nociceptive blockade produced by the anesthetic techniques tested was determined by comparing the variations in the mean arterial pressure, as well as the HR, with the surgical incision and postoperative pain assessment.

Patient satisfaction with the anesthetic techniques was evaluated using a two-point score: 1 = satisfactory (if necessary, I would have the same anesthetic technique again) and 2 = unsatisfactory (different anesthetic technique).

Postoperatively, the patients were monitored and assessed every hour for 12 h for pain score [using visual analogue scale (VAS) (0 = no pain, 10 = worst pain) and analgesic requirement], Ramsay sedation scale [8] (1 = anxious and agitated, 6 = unresponsive), vomiting, and urinary retention.

For each patient, the following data were collected: age, sex, body weight, duration of surgery, onset and duration of sensory and motor block, success in providing adequate anesthesia, hemodynamic changes, time to first analgesic requirement, incidence of postoperative complications, and patient satisfaction.

Statistical analysis

The sample size was calculated by Epicalc 2000 (USA) software program (single proportion). The minimal sample size was 60 by type I error (α) = 5% with 95% confidence level and type II error [β = 10% with power of test 90% where the complication percent from pilot study was 10 and 40% from reference (from other study)]. This was divided into 30 patients into two groups. Significance level was 0.05 (type I error, α).

All numerical variables were presented as mean (SD) and were compared using Student's t-test; all categorical variables were presented as number of patients (%) and were compared using the χ2 -test. The software used was SPSS 18 (SPSS Inc., Chicago, Illinois, USA).

Randomization of patients was performed using the following table:

[INLINE:1]

Results

As for age, sex, body weight, height, and duration of surgery, there were no statistically significant differences between both groups (P > 0.05). Regarding the technique time, the fascia iliaca group was significantly faster than the epidural group (P < 0.05) [Table 1].{Table 1}

Regarding the decrease in BP at the 20 th and 30 th minute after initiation of the local anesthesia, there was a significant difference between both groups, with more decreases in the epidural group A (P < 0.05). Otherwise, no differences were detected in the whole BP measurement throughout the operation (P > 0.05) [Table 2].{Table 2}

HR measurement showed significant increase in the HR in the 20 th , 30 th , and 40 th minutes in the epidural group (P < 0.05). Otherwise, measurements performed during the whole operation were nonsignificant (P > 0.05) [Table 3].{Table 3}

Measurements of the oxygen saturation in the arterial blood over the time of the operation showed nonsignificant differences among both groups (P > 0.05) [Table 4].{Table 4}

Total amount of ephedrine used intraoperatively was calculated for both groups and showed significant higher amounts of ephedrine used among the epidural group (P < 0.05) [Table 5].{Table 5}

Pain assessment by VAS showed no statistically significant difference between the two groups (P > 0.05) [Table 6].{Table 6}

Ramsay sedation score showed no statistically significant differences between the two groups (P-value was not calculated because both groups had zero scores).

The incidence of postoperative vomiting was higher in the epidural group A (five of 30 patients) compared with the fascia iliaca group B (0 of 30 patients). However, the difference was statistically nonsignificant (P > 0.05). With respect to postoperative urinary retention, there was significantly higher incidence of urinary retention in the epidural group A (P < 0.05) [Table 7].{Table 7}

Both groups showed satisfaction pointing to postoperative pain management, but patients within the fascia iliaca group B showed higher degree of satisfaction because of easy positioning and the absence of fear that the other group A experienced by insertion of a needle in their backs; this was statistically significant (P < 0.05) [Table 8].{Table 8}

Discussion

This study demonstrated the ability to produce postoperative analgesia in patients undergoing unilateral fixation of a fractured neck femur or knee arthroplasty. However, epidural technique is still widely used for postoperative analgesia after knee or hip surgeries.

Performing fascia iliaca block with 0.125% bupivacaine provided effective, limb-specific analgesia with fewer complications encountered commonly with epidural anesthesia, such as hemodynamic instability, postoperative vomiting, and urinary retention.

Our study was concordant with the study by Francois and Jean-Marie [9] who studied postoperative analgesia after total knee arthroplasty comparing between patient-controlled epidural analgesia and continuous 'three-in-one' block.

It is worthy to mention that our results were comparable with his study in that there was no significant difference in postoperative VAS between the two groups. In addition, in agreement with our study, the incidence of side effects with respect to vomiting and urinary retention was higher in the epidural group and showed significant difference. Nonetheless, in his study, patients favored the epidural analgesia with significant satisfaction difference, but it is worthy to put into consideration the educational and cultural differences between the study groups.

Thereafter, in 2004, Davies et al. [10] performed a study that compared between epidural analgesia and PNB, regarding postoperative analgesia, in patients undergoing knee arthroplasty. The patients were randomized to receive either lumbar epidural bupivacaine infusion or femoral (three-in-one) nerve blocks using bupivacaine 0.375%. All patients received standard general anesthesia [10] .

In contrast to our study, they found that patients who received PNB had lower pain scores at 24 h postoperatively; this could be attributed to their use of higher concentrations of bupivacaine (0.375%). Yet, in concordance to our study, the incidence of vomiting was found to be nonsignificant between both groups; the incidence of urinary retention was significantly lower in the PNB group. In addition, patient satisfaction was higher in the PNB group than in the epidural group.

CFNB began to draw the attention for giving patients analgesia with fewer complications than epidural anesthesia; this was revealed by a study performed by Barrington et al. [11] comparing CFNB versus epidural analgesia following total knee replacement. Concomitant to our study, pain was equivalent for both groups with no statistical significance. In addition, in agreement with our study, vomiting was less in the femoral nerve block group and this was statistically significant [11] .

Another study conducted by Capdevila et al. [12] reported similarly that femoral nerve block alone as a postoperative analgesic technique caused less side effects postoperatively than epidural analgesia.

Both studies conducted general anesthesia (GA) for all patients, but, with respect to postoperative data, Barrington et al. [11] reported less post operative nausea and vomiting (PONV) in the PNB group, whereas Capdevila et al. [12] reported more hypotension and urinary retention in patients who received epidural analgesia, and both are in agreement with our results.

In the following years, the continuous PNB has been intensively studied leading to a study performed by Zaric et al. [13] comparing between epidural analgesia and PNB in patients scheduled for total knee replacement; in their study, evaluation of lumbar epidural analgesia was compared with CFNB and sciatic nerve block. The standard anesthetic technique was GA for both groups. In concordance with our study, the incidence of urinary retention and overall side effects was much lower in the PNB group than in the epidural group. Despite combining the sciatic nerve with the femoral nerve block, pain was significantly lower in the epidural. It is worthy to mention that their technique was lacking the obturator nerve block, which forms one of the major nerve supplies of the knee, thus making our technique more advantageous [13] .

Our results were concordant with the results of Bosch et al. [14] who evaluated the effectiveness of a psoas compartment block, as compared with an epidural, for postoperative analgesia following total hip replacement surgery. The fascia iliaca block gives neurotomal and dermatomal distribution very similar to that of the psoas block, but the approach differs [14] .

Their study showed that there were no statistically significant differences between the two groups regarding postoperative pain, which was concordant to our results. In contrast, it showed that there was no significant difference between side effects in each group detected statistically, and this could be explained by small cohort number (20 patients) studied in each group.

Sundarathiti et al. [15] compared CFNB and continuous epidural infusion in postoperative analgesia and knee rehabilitation after total knee arthroplasty.

In contrast to our study, the study showed significant difference in postoperative pain assessment using VAS that favored epidural analgesia, and this could be attributed to the blockage of the femoral nerve alone, which was not enough for producing analgesia in knee surgeries. However, in our study, the use of fascia iliaca block provided better analgesia by blocking the femoral, lateral femoral cutaneous nerve, and anterior and posterior branches of the obturator nerve. However, the incidence of nausea and vomiting was still detected in the epidural group and was statistically significant. Patient satisfaction was also higher with the CFNB group, which was statistically significant.

Our study was comparable with the study by Balderi and Carli [16] , who studied the urinary retention after total hip and knee arthroplasty and revealed that epidural analgesia showed significant incidence of urinary retention than continuous PNBs and recommended the use of the later whenever possible.

Our results are in agreement with the results of Gallardo et al. [17] , who compared postoperative analgesia from a fascia iliaca compartment block to continuous epidural analgesia following knee arthroplasty; both groups received spinal anesthesia. In their study, arterial hypotension was significantly higher in the epidural group compared with the fascia iliaca group. Postoperative pain assessment using VAS showed no statistical significance in both groups. In their study, they used nearly the same local anesthetic concentration of 0.1% bupivacaine HCl with the same rates of infusion used in our study [17] .

Our results are comparable with the results of Scott et al. [18] who compared femoral nerve block with patient-controlled epidural analgesia for postoperative pain control of total knee arthroplasty, which showed no significant difference in pain assessment using VAS between the two groups. However, no statistically significant difference was found in the incidence of any reported side effects including urinary retention, nausea, and vomiting, and this could be due to small cohort number (14 patients) in each group [18] .

Rashwan [19] performed a similar study comparing patient-controlled epidural analgesia with patient-controlled fascia iliaca block analgesia for fixation of fracture neck femur. In her study, pain was less in the epidural group compared with the fascia iliaca block group, which was statistically significant; this may be attributed to the use of small initial volume infused in the fascia iliaca group (30 ml of bupivacaine HCl), whereas we used 40-50 ml as an initial volume. It is also important to point out that she used patient-controlled analgesia, which made the use of local anesthetics interrupted; however, the advantage of our technique is that we used continuous infusion to maintain adequate level of analgesia. Nevertheless, the BP decreased and the HR increased with the epidural group, but they were statistically insignificant, and this is because she measured BP and HR only during the postoperative period and no measurements were performed during the intraoperative period [19] .

Conclusion

We conclude that continuous fascia iliaca block provides effective unilateral analgesia in patients undergoing fixation of fractured femur neck and shaft or knee arthroplasty with a high patient satisfaction rate and low incidence of hemodynamic instability and postoperative nausea and vomiting when compared with epidural analgesia.

Acknowledgements

Conflicts of interest

None declared.

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