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Reducing Delirium with Fascia Iliaca US-Guided Block

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Written by Chris Thom

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In this multicenter randomized trial of elderly patients with hip fractures, there was a significant reduction in delirium in those patients who received ultrasound-guided fascia iliaca blocks.

Regional anesthesia is worth your time 
This multicenter randomized study enrolled patients at 7 academic EDs in Canada. It incorporated a stepped-wedge randomization cluster, wherein emergency physicians with minimal prior nerve block experience received a dedicated knowledge-to-practice training intervention on fascia iliaca blocks. This training occurred at different time points for different physicians. A total of 208 out of 213 eligible ED physicians were trained.  The primary outcome was the proportion of patients with delirium within 7 days of admission. 

732 patients were randomized, with 264 (36.6%) treated before physician training and thus assigned to the control group, while 468 (63.4%) were treated after training and were assigned to the intervention group. In the control group, 31% of patients developed delirium, compared to 26% in the intervention group (OR 0.72; 95%CI 0.57-0.93). Overall, nerve blocks were performed in 2.2% of patients in the control group and 52.9% in the intervention group.

How will this change my practice?
This is a patient-centered outcome that we can impact as ED physicians. Hip fractures in the elderly carry significant morbidity, and we have an easily deployed tool that can reduce pain, opioid consumption, and frequency of delirium in one fell swoop. We are all overworked and understaffed, and the need to click the next EHR box is a powerful force to counter. However, we have additional evidence now that our patients directly benefit when we walk away from the EHR for a few minutes and deliver this proven bedside therapy instead.

POCUS pro-tips and clips
The fascia iliaca block is a friendly and safe modality for delivering hip fracture analgesia. I’ve found that the more common infrainguinal fascia iliaca block is a bit easier to master, with more standardized and recognizable anatomy. We start by finding the femoral artery and femoral vein and then moving slightly laterally over to the iliacus muscle. The biggest pitfall I see with trainees is going too caudal. If you are not seeing the sartorius muscle nicely layering over the iliacus muscle, then try sliding up towards the inguinal ligament. 

fascia iliaca block POCUS image

Source
Ultrasound-Guided Regional Anesthesia by Emergency Physicians for Hip Fractures and Delirium: A Randomized Clinical Trial. JAMA Netw Open. 2025 Dec 1;8(12):e2549337. doi: 10.1001/jamanetworkopen.2025.49337. PMID: 41396601; PMCID: PMC12706686.

View JournalFeed Critical Appraisal

Critical Appraisal

Title: Ultrasound-Guided Regional Anesthesia by Emergency Physicians for Hip Fractures and Delirium: A Randomized Clinical Trial.
Background: Delirium is a common and serious complication of hip fractures in the elderly, leading to increased mortality and healthcare costs. Regional anesthesia may reduce delirium risk, but its use by ED physicians is limited.
Study Question: Can a knowledge-to-practice intervention increase the use of POCUS-GRA by ED physicians and reduce delirium in elderly hip fracture patients?
Study Design: Stepped-wedge cluster randomized clinical trial
Population: ED physicians working at least 1 shift per week and patients aged 65 years and older with hip fractures, not delirious on arrival.
Intervention: A 2-hour training session on fascia iliaca blocks for ED physicians.
Comparison: Patients treated by ED physicians before the training intervention.
Primary Outcome: Incidence of delirium within 7 days of ED presentation.
Secondary Outcomes: Duration of delirium, analgesic effectiveness, safety, and procedure time.
Key Statistics: Odds ratio for delirium in intervention group: 0.72 (95% CI, 0.57-0.93).
Results: The intervention increased nerve block use from 2.2% to 52.9% and reduced delirium odds. Nerve blocks were effective in reducing pain by 50% in 57.5% of cases.
Risk of Bias – RoB 2:
  • Bias arising from the randomization process: Randomization was appropriately conducted with stratification by expertise.
  • Bias due to deviations from intended interventions: There was some crossover and variability in training uptake.
  • Bias due to missing outcome data: Missing data was minimal and unlikely to impact results.
  • Bias in measurement of the outcome: Potential for differential measurement of delirium across sites.
  • Bias in selection of the reported result: All prespecified outcomes were reported.
Take Home: Training ED physicians in POCUS-GRA can significantly reduce delirium in elderly hip fracture patients, suggesting a potential standard of care change.
This critical appraisal is generated using a structured framework applied to the full text of the original article and is presented separately from the physician’s commentary.

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