Written by Chris Thom
Spoon Feed
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.

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
- 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.
