الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
There are approximately three out of four hip fractures occur in females In Western countries. Hip fractures occur more in females than males with a ratio of 2:1 in most countries of the world.
Arthroplasty is one of recent advancement in the treatment of hip fractures, specifically femoral neck fracture. There are two types of arthroplasty; total hip arthroplasty (THA) and hemi-arthroplasty (HA). Hemi-arthroplasty includes both unipolar and bipolar hemi-arthroplasty. At rest, approximately one-third of patients with hip fractures will have severe pain, one -third will have moderate pain and one-third will have mild or no pain. On movement, over three-quarters of patients will have moderate to severe pain.
Pain imposes an additional burden on patients with hip fractures. When pain is not effectively managed, patients are not able to walk, therefor patients are more likely to have compromised cardiac and pulmonary functions and thromboembolic complications. So, the use of multimodal analgesic approaches is a must.
FICB is a peripheral nerve block, which has become an important part of perioperative multimodal analgesic strategies in patients undergoing bipolar hip hemi arthroplasty surgery. The analgesic effect of FICB can persist for 24 hours.
Epidural analgesia has been popular over decades in perioperative multimodal analgesic strategies in patients undergoing bipolar hip hemi arthroplasty surgery.
The aim of the present study was to compare the analgesic effect of ultrasound guided FICB and lumbar epidural analgesia in patients undergoing hip hemi-arthroplasty surgery, as well as patients’ satisfaction and occurrence of complications in both groups.
The current study was carried out in El Hadara University Hospital, Alexandria University on 50 adult patients of either sex, aged 20 to 70 years and belonging to the American Society of Anesthesiologists (ASA) physical status I or II, They underwent elective unilateral hip hemi- arthroplasty surgery for treatment of fracture neck of the femur in randomized double blinded study.
Patients were excluded upon refusal of the regional block or inability to properly describe postoperative pain to the observer, or being a pregnant female or when the patient presented with coagulopathy, allergy or contraindication to the studied anesthetic agents, infection at the site of LA injection, and morbid obesity.
Patients were randomly categorized into two equal groups using the closed envelope method of randomization (twenty five patients each).
group A
Patients had received ultrasound guided FICB (in-plane approach) in the form of 40 ml of 0.25% levobupivacaine in FIC as a bolus dose. Fascia iliaca compartment catheter was inserted afterwards followed by general anesthesia.
Then patients received 5 ml levobupivacaine 0.125% per hour started immediately postoperatively in post anaesthesia care unit (PACU) and continued for 24 hours.
group B
Patients had received lumbar epidural analgesia in the form of a bolus of 20 ml of 0.25% levobupivacaine immediately after insertion of the epidural catheter in 5 ml increments over 15 minutes, followed by general anesthesia. After that 5 ml levobupivacaine 0.125% per hour infusion started immediately postoperatively in PACU and continued for 24 hours.
All the patients were evaluated the day before the surgery.
All patients were informed with the anesthetic techniques and trained to use the visual analogue scale (VAS).
On arrival to the block room a peripheral intravenous line was inserted in all patients. Multichannel monitor was attached to patients to displaying electrocardiogram (lead II), heart rate (beats/min), non-invasive systolic, diastolic, and mean arterial blood pressure (mmHg), and peripheral oxygen saturation (SpO2%). Baseline data were recorded.
With the patient in the supine position ultrasound guided fascia iliaca compartment block was performed. The ultrasound probe was placed in the inguinal region 1cm below the junction of medial two-third and lateral one-third of the line joining the anterior superior iliac spine and pubic tubercle, the femoral sheath was identified, the probe was moved a little toward the lateral, sothat iliopsoas muscle was specified as a hypo echo part lateral to the femoral artery and nerve. After subcutaneous infiltration with 2 ml lidocaine 1% at the needle entry site, an 18 G tuohy needle was introduced by in-plane approach, then a 40 ml of local anaesthetic 0.25% levobupivacaine were injected between fascia iliaca layer and Iliopsoas muscle after piercing fascia iliaca layer. For longer lasting analgesia, a flexible epidural_type catheter was threaded through the needle into fascia iliaca compartment for one day after surgery.
Epidural catheter was inserted at L3 to L 4 with patient in lateral decubitus position, with the surgical side upward. The patient arched the back bringing the chin and flexed knee toward the chest.
Both midline and Para median approaches were used. Two ml of lidocaine 1% were injected in to insertion site.
The standard tuohy needle (18_gauge) was advanced inferior to L3 spinous process, needle slightly cephaled to follow inferior border of L3.
The needle was advanced through the skin, subcutaneous tissue with the stylet in place until the- inter spinous ligament was pierced. The stylet was removed and a low resistance plastic syringe was attached to the hub of needle. Advance the needle slowly. When the -needle entered epidural space, loss of resistance was felt and the plunger of syringe advanced freely. After insertion of the needle in the epidural space, the distance from the skin at which epidural space lie was noted and the epidural catheter was advanced 3 to 5 cm in the epidural space.
All patients were transferred to the operation room 20 minutes after the insertion of either FICB catheter or epidural catheter and administration of bolus doses of levobupivacaine.