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Anaesthesia - Fascia iliaca block

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Indications

Neck of femur fracture

Femoral fracture

Contraindications (absolute in bold)

Allergy to local anaesthetic

Local infection

Heart block (without pacemaker)

Previous femoral bypass surgery

Unable to identify femoral artery on US

Hepatic disease

Coagulopathy (INR >1.5, heparin or NOAC within 12 hours, platelets <100)

Alternatives

Femoral nerve block

Blind double-pop fascia iliaca block (without ultrasound)

Oral or IV analgesia

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Failure (ineffective pain relief)

Allergy

Neurovascular damage

Haematoma

Infection

Local anaesthetic toxicity

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: sterile gloves, sterile drape, sterile US cover and gel

Area

Monitored bed

Staff

Procedural clinician

Assistant

Equipment

Ultrasound with linear array probe usually in the mid-to high-frequency range (e.g. 8-10MHz)

50-60ml Luer lock syringe (or 20ml x 2)

Nerve block needle e.g. 22g x 50mm Sono Tap® cannula (easy to visualise on ultrasound)

Minimal volume extension tubing

Small dressing

Marking pen

Positioning

Supine position with the affected limb slightly abducted and externally rotated if possible.

Medication

Lignocaine 1% 5ml for skin anaesthesia

then

Ropivacaine 0.375% 40ml (3mg/kg maximum), or

Bupivacaine 0.25% 40ml (2mg/kg maximum)

Sequence

Perform on injured side of patient with ultrasound machine opposite

Palpate the ASIS and mark the medial border

Palpate the femoral artery and mark its position

Hold the ultrasound probe in non-dominant hand and the needle in the dominant hand

Anaesthetise 2cm lateral to the femoral artery and 1cm inferior to the inguinal ligament (insertion point)

Place the ultrasound probe parallel to the inguinal ligament, between the ASIS and the femoral artery

Palpate and place the probe over the ASIS moving medially to identify the common femoral artery

Palpate and place the probe over the ASIS and identify on the ultrasound

Move the probe medially 2-3cm and inferiorly and identify the edge of the ilium

Identify the muscle covering the ilium and descending into the pelvis (the iliacus muscle)

The bright band covering the iliacus is the fascia iliacus

Move the probe superiorly over the edge of the ilium to show ilium, fascia and iliacus muscle

Stabilise the hand holding the ultrasound probe to minimise movement

Using an out-of-plane needle approach for this block, the needle tip may be visualised as a hyperechoic dot

Angle the needle to cross the iliacus fascia about midway across the bony edge of the ilium

You should feel a release and see the needle tip puncture the iliacus fascia

Keep the needle tip in the superficial layers of the iliacus muscle

Once the needle tip is subfascial, aspirate and inject 2-5ml of the local solution to see how it spreads

The solution will lift the fascia off the superficial layer of the iliacus muscle and spread in a superior direction

After injecting 5-10ml, advance the needle another centimetre into the space made by the injection

Inject the remainder of the local solution slowly over 1½-2 minutes, aspirating every 5ml

Adjust the needle position, if necessary, to correct placement of the solution

Withdraw the needle and apply dressing with gentle pressure

Post-procedure care

Monitoring

Carry out continuous cardiac monitoring for 15 minutes post procedure

Monitor hourly for two hours, then every four hours (general observation chart and pain assessment)

Ongoing care

Provide and chart oral pain relief

Give tetanus (ADT) and antibiotic cover (cefazolin 2g IV) for open wounds

Discuss ongoing management with orthopaedic team

Document verbal consent, local anaesthetic given, procedure and immediate complications

Tips

Ultrasound guidance is strongly recommended to increase success and minimise complications

Ropivacaine is the preferred local anaesthetic agent due to prolonged action and reduced cardiac toxicity

Ropivacaine usually comes in a 0.75% solution and requires dilution 1:1 with saline to 0.375%

If resistance to injecting is felt, withdraw needle slightly as it may be in muscle below fascia

Discussion

High‐quality evidence shows that peripheral nerve blocks reduce pain on movement within 30 minutes after block placement, and moderate‐quality evidence shows that they reduce risk of pneumonia and time to first mobilisation. Femoral nerve blocks have similar levels of efficacy and can be used as an alternative if the provider is more comfortable with this block. We prefer the fascia iliaca block due the lower risk of accidental arterial puncture.

Inadvertent intravascular injection can cause local anaesthetic toxicity which occurs in approximately 20 in 100,000 procedures This risk can be reduced by good technique and the use of ultrasound. Inadvertent intravascular injection is suggested by circumoral tingling, light-headedness, visual disturbances, seizures or arrhythmias. If these signs occur, stop injecting the local anaesthetic and call for assistance. If unresponsive to standard cardiopulmonary resuscitation, commence lipid rescue with intralipid 20%. In practice, this requires resuscitating an adult weighing 70kg as follows:

Take a 500ml bag of intralipid 20% and a 50ml syringe

Draw up 50ml and give stat IV, x 2

Attach the intralipid bag to an IV administration set and run the IV at rate 1050ml/hour infusing the remainder

Repeat the initial bolus up to twice more if spontaneous circulation has not returned

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

NSW Agency for Clinical Innovation. Fascia iliaca block: a method of preoperative pain management in older people with acute hip fractures. Sydney: ACI; 2017. 27pp. Available from: https://www.aci.health.nsw.gov.au/resources/aged-health/hip-fracture/fascia-iliaca-block

Guay J, Parker MJ, Griffiths R, Kopp S. Local anaesthetic nerve blocks for people with a hip fracture. Cochrane database of systematic reviews 2017. Issue 5. Art. No.: CD001159 Available from: https://www.cochrane.org/CD001159/ANAESTH_local-anaesthetic-nerve-blocks-people-hip-fracture

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges' clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Steenberg J, Moller AM. Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation. Br J Anaesth. 2018 Jun;120(6):1368-1380.

Ritcey B, Pageau P, Woo MY, Perry JJ. Regional nerve blocks for hip and femoral neck fractures in the emergency department: a systematic review. CJEM. 2016; 18(1):37-47 doi: 10.1017/cem.2015.75.

Newman B, McCarthy L, Thomas PW, May P, Layzell M, Horn K. A comparison of pre-operative nerve stimulator-guided femoral nerve block and fascia iliaca compartment block in patients with a femoral neck fracture. Anaesthesia.

Anaesthesia. 2013 Sep;68(9):899-903 doi: 10.1111/anae.12321.

Reavley P, Montgomery AA, Smith JE, Binks S, Edwards J, Elder G, Benger J. Randomised trial of the fascia iliaca block versus the ‘3-in-1’ block for femoral neck fractures in the emergency department. Emerg Med J. 2015 Sep;32(9):685-9 doi: 10.1136/emermed-2013-203407.

© Agency for Clinical Innovation 2021