European Journal of Cardiovascular Medicine

Regional anesthesia is a choice of treatment for reduction of side-effects associated with analgesics and to provide better relief in the pain which is usually advantageous in elderly subjects with hip fracture and limited cardiopulmonary reserves. Hence, techniques and medications with better tolerance and lesser side-effects are considered ideal to provide postoperative analgesia.¹

FICB or fascia iliaca compartment block was first described in the year 1989 by Dalens and is used widely for femur and hip surgeries as a simple alternative for femoral and lumbar plexus nerve blocks. FICB targets the lateral cutaneous, obturator, and femoral nerves by injection of local anesthetic agent under fascia iliaca which can be considered as an anterior approach for lumbar plexus.²

FICB is a reasonable, easy, and safe substitute for femoral and lumbar plexus blocks in the clinical scenario. Despite infrainguinal and suprainguinal approaches being different anatomically, there is scarce literature data for their comparison.³ Hence, the present study was aimed to comparatively assess the suprainguinal and infrainguinal approaches for fascia iliaca compartment block for providing postoperative analgesia in subjects undergoing hip surgeries.

The present prospective randomized clinical study was aimed to comparatively assess the suprainguinal and infrainguinal approaches for fascia iliaca compartment block for providing postoperative analgesia in subjects undergoing hip surgeries. The study subjects were from Department of Anesthesia of the Institute. Verbal and written informed consent were taken from all the subjects before study participation.

The study included 160 subjects that were two groups of 80 subjects each where Group I subjects used suprainguinal approach and Group II subjects as infrainguinal approach using 30ml of 0.25% bupivacaine. For emergency analgesia, 50mg tramadol was given. Group I subjects were given FICB using suprainguinal approach and Group II subjects were given FICB using infrainguinal approach.

The study included subjects aged 18-60 years undergoing elective hip surgeries as core decompression, dynamic hip screws, proximal femoral nailing, unipolar or bipolar hemiarthroplasty, and/or total hip replacement under lumbar subarachnoid block lasting for 90-120 minutes. The exclusion criteria for the study were subjects with ASA status of III or higher, subjects unable to provide VAS score, unable to comprehend, with neurological impairments in the lower limbs, infections at the site of the block, with allergies to local anaesthetics, and subjects on chronic analgesics. After inclusion, detailed history was recorded for all the subjects followed by physical examination and routine pre-anesthesia assessment for all the subjects including VAS scores explanation.

All subjects were given premedication using 0.025mg/kg intravenous midazolam and received lumbar subarachnoid blockade with 2ml of 0.5% bupivacaine in the lateral position. Subjects were preloaded using 10 mL/kg of lactated Ringer’s solution. Later subjects were placed in supine position and given FICB using infrainguinal approach of Dalens.⁴ Needle was inserted at a point 1cm below intersection of the middle and outer thirds of the line connecting the pubic tubercle and the anterior superior iliac spine (ASIS). The needle was inserted at a right angle until the first "pop" or loss of resistance (fascia lata) was felt. Following a negative aspiration test, 30 mL of 0.25% bupivacaine was injected while applying firm compression below the injection site.

For Group I subjects FICB was given utilizing modified suprainguinal approach as described by Stevens.⁵ Needle was inserted 1 cm above the midpoint between the pubic tubercle and ASIS, advancing until the second “pop” (iliac fascia) was felt. Similar to Group I, 30 mL of 0.25% bupivacaine was administered after confirming the absence of vascular puncture through aspiration testing.

Intraoperatively, standard care was given to all the subjects including intravenous medications including antibiotics. Midazolam was used for sedation maintenance. Blood lost was replaced with appropriate volumes of balanced salt solutions. Bradycardia was managed with atropine and 250mL balanced salt solution fluid boluses. Analgesia duration was recorded as time from block administration to the first postoperative complaint of pain (VAS >4). Hemodynamic parameters and pain scores were assessed at baseline, 5, 10, 15, 30, and 60 minutes, and at 2, 4-, 6-, 18-, and 24-hours post-surgery.

For postoperative care intravenous antibiotics and low-molecular-weight heparin was given. Subjects that needed additional analgesia were given 100 mg tramadol in subjects with VAS scores more than 4. In both groups, block puncture site was covered using sterile dressings. In both the groups, demographic data were recorded. Parameters recorded were time of the initial administration of a rescue analgesic, visual analogue score (VAS) for pain, total amount of tramadol consumed in a 24-hour period, and adverse event as vomiting, nausea, hypotension, and/or bradycardia.

The present prospective randomized clinical study was aimed to comparatively assess the suprainguinal and infrainguinal approaches for fascia iliaca compartment block for providing postoperative analgesia in subjects undergoing hip surgeries. The study assessed 160 subjects to compare the analgesic efficacy of two techniques of FICB. These subjects were randomly divided into two groups of 80 subjects each where Group I subjects used suprainguinal approach and Group II subjects as infrainguinal approach using 30ml of 0.25% bupivacaine. For emergency analgesia, 50mg tramadol was given. There were 156 male and 44 female subjects in Group I and 136 males and 64 females in Group II. Mean age of study subjects was 38.05±15.56 and 40.71±15.97 years respectively in Group I and II. Mean BMI in group I and II was 21.68±0.97 and 21.71±0.96 kg/m2. Mean surgical duration was 113.50±10.90 and 115.74±10.82 minutes in Groups I and II respectively (Table 1).

Table 1: Distribution of demographic characteristics in two groups of study subjects

It was seen that for number of tramadol doses in 24 hours and time for rescue analgesia in two groups of study subjects, mean number of tramadol doses in 24 hours were 14.13±3.07 in Group I and 24.13±8.94 in Group II which was significantly higher in Group II with p=0.01. Time for first rescue analgesia was 284.87±6.07 minutes in Group I and 189.03±12.76 minutes in Group II which was significant with p=0.008 (Table 2).

Table 2: Number of tramadol doses in 24 hours and time for rescue analgesia in two groups of study subjects

The study results showed that for VAS scores in two study groups at different time interval, a non-significant difference in VAS scores was seen at baseline, 5 minutes, 10 minutes, 15 minutes, 30 minutes, 60 minutes, and 2 hours in two groups with p=0.22, 0.00, 0.00, 0.00, 0.00, 0.00, and 0.00 respectively. VAS scores were significantly higher in Group II compared to Group I at 4 hours, 6 hours, 18 hours, and 24 hours with p=0.01, 0.004, <0.001, and <0.001 respectively (Table 3).

Table 3: VAS scores in two groups of study subjects at different time intervals

Concerning the adverse effects in two groups of study subjects, bradycardia was seen in 2 subjects from Group I and 4 subjects from Group II with p=0.423. A non-significant difference was seen for urinary retention incidence in two groups of study subjects with p=0.926. Incidence of hypotension, vomiting, and nausea was significantly higher with infrainguinal approach compared to suprainguinal approach with p=0.03, <0.001, and <0.001 respectively (Table 4).

Table 4: Adverse effects in two groups of study subjects

The present study assessed 160 subjects to compare the analgesic efficacy of two techniques of FICB. These subjects were randomly divided into two groups of 80 subjects each where Group I subjects used suprainguinal approach and Group II subjects as infrainguinal approach using 30ml of 0.25% bupivacaine. For emergency analgesia, 50mg tramadol was given. There were 156 male and 44 female subjects in Group I and 136 males and 64 females in Group II. Mean age of study subjects was 38.05±15.56 and 40.71±15.97 years respectively in Group I and II. Mean BMI in group I and II was 21.68±0.97 and 21.71±0.96 kg/m2. Mean surgical duration was 113.50±10.90 and 115.74±10.82 minutes in Groups I and II respectively. These data were comparable to the previous studies of Krych AJ et al⁶ in 2014 and Shariat AN et al⁷ in 2013 where authors assessed subjects with demographic data comparable to the present study in their respective studies.

The study results showed that for number of tramadol doses in 24 hours and time for rescue analgesia in two groups of study subjects, mean number of tramadol doses in 24 hours were 14.13±3.07 in Group I and 24.13±8.94 in Group II which was significantly higher in Group II with p=0.01. Time for first rescue analgesia was 284.87±6.07 minutes in Group I and 189.03±12.76 minutes in Group II which was significant with p=0.008. These results were consistent with the findings of Foss NB et al⁸ in 2007 and Bullock WM et al⁹ in 2017 where tramadol doses in 24 hours and time for rescue analgesia reported by the authors in their studies was comparable to the results of the present study.

It was seen that for VAS scores in two study groups at different time interval, a non-significant difference in VAS scores was seen at baseline, 5 minutes, 10 minutes, 15 minutes, 30 minutes, 60 minutes, and 2 hours in two groups with p=0.22, 0.00, 0.00, 0.00, 0.00, 0.00, and 0.00 respectively. VAS scores were significantly higher in Group II compared to Group I at 4 hours, 6 hours, 18 hours, and 24 hours with p=0.01, 0.004, <0.001, and <0.001 respectively. These findings were in agreement with the results of Arrola GL et al¹⁰ in 2009 and Kehlet H et al¹¹ in 2001 where VAS score results comparable to the present study were also reported by the authors in their respective studies.

The study results also showed that for the adverse effects in two groups of study subjects, bradycardia was seen in 2 subjects from Group I and 4 subjects from Group II with p=0.423. A non-significant difference was seen for urinary retention incidence in two groups of study subjects with p=0.926. Incidence of hypotension, vomiting, and nausea was significantly higher with infrainguinal approach compared to suprainguinal approach with p=0.03, <0.001, and <0.001 respectively. These findings correlated with the results of Kumar K et al¹² in 2015 and Ahluwalia P et al¹³ in 2025 where adverse effects similar to the present study were also reported by the authors.

Within its limitations, the present study concludes that suprainguinal FICB approach has superior analgesic efficacy and lower consumption of postoperative tramadol within 24 hours in comparison to infrainguinal approach in subjects undergoing surgery for hip fractures.

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