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Fascia Iliaca Compartment Block and Intravenous Fentanyl for Positioning During Spinal Anaesthesia in Fracture Femur Surgeries - a Randomized Controlled Study

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COMPARATIVE EVALUATION OF FASCIA ILIACA COMPARTMENT BLOCK AND INTRAVENOUS FENTANYL FOR POSITIONING DURING SPINAL ANAESTHESIA IN FRACTURE FEMUR SURGERIES - A RANDOMIZED CONTROLLED STUDY Dissertation submitted in partial fulfillment of the requirements for award of the degree M.D. (Anaesthesiology) Branch X GOVT. KILPAUK MEDICAL COLLEGE CHENNAI-10 THE TAMIL NADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI, TAMILNADU APRIL 2017. CERTIFICATE This is to certify that this dissertation entitled “COMPARATIVE EVALUATION OF FASCIA ILIACA COMPARTMENT BLOCK AND INTRAVENOUS FENTANYL FOR POSITIONING DURING SPINAL ANAESTHESIA IN FRACTURE FEMUR SURGERIES - A RANDOMIZED CONTROLLED STUDY” submitted by Dr.DEEPA K in partial fulfillment for the award of the degree Doctor of Medicine in Anaesthesiology by The TamilNadu Dr.M.G.R. Medical University, Chennai is a bonafide work done by her at GOVERNMENT KILPAUK MEDICAL COLLEGE, CHENNAI during the academic year 2014-2017. Prof.Dr.R.Narayana Babu,M.D.,DCH., Prof.Dr.T.Murugan,M.D.,D.A., Dean, Professor & HOD, Govt. Kilpauk Medical College, Department of Anaesthesiology, Chennai-10. Govt. Kilpauk Medical College, Chennai – 10. DECLARATION BY THE GUIDE This is to certify that this dissertation entitled “COMPARATIVE EVALUATION OF FASCIA ILIACA COMPARTMENT BLOCK AND INTRAVENOUS FENTANYL FOR POSITIONING DURING SPINAL ANAESTHESIA IN FRACTURE FEMUR SURGERIES - A RANDOMIZED CONTROLLED STUDY” submitted by Dr.DEEPA K in partial fulfillment for the award of the degree Doctor of Medicine in Anaesthesiology by The Tamilnadu Dr.M.G.R. Medical University, Chennai is a bonafide work done by her at GOVERNMENT KILPAUK MEDICAL COLLEGE, CHENNAI during the academic year 2014- 2017, under my guidance and supervision. Prof.Dr.S.Krishna Kumar, M.D., Professor Of Anaesthesiology , Department of Anaesthesiology, Govt. Kilpauk Medical College, Chennai – 10. DECLARATION I, Dr.DEEPA K, solemnly declare that this dissertation, entitled “COMPARATIVE EVALUATION OF FASCIA ILIACA COMPARTMENT BLOCK AND INTRAVENOUS FENTANYL FOR POSITIONING DURING SPINAL ANAESTHESIA IN FRACTURE FEMUR SURGERIES - A RANDOMIZED CONTROLLED STUDY” has been prepared by me, under the expert guidance and supervision of Prof.Dr.T.Murugan,M.D.,D.A, Professor and HOD, Department of Anaesthesiology, Government Kilpauk Medical College and Hospital, Chennai and submitted in partial fulfillment of the regulations for the award of the degree M.D.(Anaesthesiology) by The Tamil Nadu Dr. M.G.R. Medical University and the examination to be held in April 2017. This study was conducted at Government Kilpauk Medical College Hospital and Government Royapettah Hospital, Chennai. I have not submitted this dissertation previously to any university for the award of any degree or diploma. Place: Chennai Date: DR. DEEPA K ACKNOWLEDGEMENT I wish to express my sincere thanks to Dr.R.Narayana Babu,M.D.,DCH., Dean, Government of Kilpauk Medical College, Chennai for having kindly permitted me to utilize the facilities of the college for the conduct of the study. I am extremely grateful to the Professor and Head of the Department of Anaesthesiology, Govt. Kilpauk Medical College, Prof. Dr. T.Murugan, M.D.,D.A., for his motivation, valuable suggestions, inspiration, meticulous guidance, expert advice and constant encouragement in preparing this dissertation and for providing all necessary arrangement for conducting the study. I am grateful and indebted to Prof. Dr. R. Kundhavi Devi, M.D.,D.A., Professor, Department of Anaesthesiology, Government Kilpauk Medical College, Chennai for her concern. I also express my sincere gratitude to all other Professors of Anaesthesiology, KMC, Prof. Dr.Valli Sathyamoorthy, MD., DA., Prof. Dr. A.Chandrasekar , M.D., Prof. Dr. S. Krishna Kumar, M.D., for their constant motivation, encouragement and valuable suggestions. I thank all the Assistant Professors of Anaesthesiology KMCH and GRH for their keen interest and support without which this study would not have been possible. I am thankful to the Institutional Ethical Committee for their guidance and approval of the study. I also thank my colleague postgraduates for supporting me throughout the study. I thank the Department of Orthopaedics, KMCH and GRH and their faculty members for their kind cooperation and permitting me to use the hospital facilities for the study. I also thank the theatre personnel for their co-operation and assistance. I wish to thank all the patients whose willingness and patience made this study possible. I finally thank God Almighty for His blessings in successfully completing the study. TABLE OF CONTENTS S.NO TITLE PAGE NO 1 INTRODUCTION 1 2 AIMS AND OBJECTIVES 3 3 ULTRASONOGRAPHY 4 4 ANATOMY OF NERVES OF LOWER LIMB 16 5 FASCIA ILIACA COMPARTMENT BLOCK 25 6 CLINICAL PHARMACOLOGY-BUPIVACAINE 29 7 CLINICAL PHARMACOLOGY-FENTANYL 34 8 REVIEW OF LITERATURE 38 9 MATERIALS AND METHODOLOGY 47 10 OBSERVATION AND RESULTS 56 11 DISCUSSION 86 12 SUMMARY 91 13 CONCLUSION 93 14 BIBLIOGRAPHY 94 ANNEXURES S.NO TITLE INSTITUTIONAL ETHICAL COMMITTEE 1 APPROVAL 2 PROFORMA 3 PATIENT CONSENT FORM 4 MASTER CHART INTRODUCTION Regional anaesthesia is the most widely used anaesthetic technique for orthopaedic procedures in lower limbs1. Regional anaesthesia has many advantages over general anaesthesia as it provides a good perioperative pain relief, reduces systemic analgesic requirements, decreases poly pharmacy, avoids unnecessary airway manipulation, permits early ambulation and decreases chances of deep vein thrombosis.2 Fracture Femur is a common orthopaedic injury which causes severe pain and distress to the patient as the periosteum has the lowest pain threshold of the deep somatic structures3. Anaesthesia for femur surgeries is usually provided by subarachnoid block. Proper positioning during subarachnoid block is essential for a successful procedure. However, over riding of bone ends during movement worsens pain, delays positioning which in turn increases pain further. Alleviating pain increases patient comfort and also provides better patient positioning for subarachnoid block. Various drugs like Non-steroidal anti-inflammatory drugs, opioids, midazolam, ketamine, propofol have been in use to reduce the pain pre- operatively and improve positioning in these patients. Nerve blocks have come up as an effective and a safe alternative to provide pain relief . 1 Different techniques have been used to identify and block nerve fibres. Blockade of peripheral nerves have evolved a long way from blind approaches eliciting paresthesia initially, to the use of peripheral nerve stimulators and to the use of ultrasound off late. Earlier, nerve blocks were performed using landmark techniques and by eliciting paraesthesia. They were associated with highfailure rates and caused injury to the nerves and surrounding structures. Nerve stimulators were invented for higher success rates and to decrease the complications. It ensured a better blockade than conventional paraesthesia technique. But both these methods can cause neurovascular injuries leading to permanent nerve damage. Ultrasound is gaining importance in recent years and has provided anaesthesiologists, an effective alternative tool for the identification and safe blockade of nerve fibres. This study is designed to compare Fascia Iliaca Compartment Block under ultrasound guidance and intravenous fentanyl for positioning during spinal anaesthesia in femur fractures. 2 AIM OF THE STUDY To compare the efficacy of Fascia Iliaca Compartment Block under ultrasound guidance and intravenous fentanyl for positioning during spinal anaesthesia in fracture femur surgeries. OBJECTIVES PRIMARY OBJECTIVES: To compare 1. The analgesia obtained for positioning during spinal anaesthesia. 2. The ease of positioning and the time taken for giving spinal anaesthesia SECONDARY OBJECTIVES: To compare 1. Hemodynamic parameters 2. Requirement of first rescue analgesic post operatively. 3 ULTRASONOGRAPHY The normal human hearing is in the range of 20 -20,000HZ. Ultrasound denotes sound waves with a frequency above the audible range.ie. more than 20,000 cycles per second. HISTORY OF ULTRASOUND GUIDANCE FOR NERVE BLOCKS: Ting and Sivagnanaratnam4 in 1989 were among the first to use ultrasonography to perform blocks. They were 100% successful with axillary nerve blocks and visualized the nerves around the axillary artery, the needle tip and the spread of local anaesthetic at all times. Kapral et al.5 in 1994 demonstrated that ultrasound guidance for supraclavicular blocks were safer and more effective compared to axillary nerve blocks. Later in 1997, they showed that the “three-in-one” lower limb blocks had a better success rate when done using ultrasound compared to nerve stimulation technique6. The local anaesthetic requirement to perform an effective nerve block was also reduced under ultrasound guidance7. The better quality of images of brachial plexus generated by researchers in Toronto with ultrasound further lead to the advancement of the use of ultrasound for localisation of nerves. 4 PRINCIPLE OF ULTRASONOGRAPHY8: Ultrasound uses sound waves to produce an image of structures through which they pass. Ultrasound waves are emitted from piezoelectric crystals present in the probe of the ultrasound transducer. When an electric current is applied to these crystals, they rapidly change shape and vibrate and emit ultrasound waves. The process converts electrical energy into mechanical energy and is called reverse piezoelectric effect. These waves travel at different rates through tissues
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