Anaesthesia - Fascia iliaca block
Neck of femur fracture
Contraindications (absolute in bold)
Allergy to local anaesthetic
Heart block (without pacemaker)
Previous femoral bypass surgery
Unable to identify femoral artery on US
Coagulopathy (INR >1.5, heparin or NOAC within 12 hours, platelets <100)
Femoral nerve block
Blind double-pop fascia iliaca block (without ultrasound)
Oral or IV analgesia
Consent is not required if the patient lacks capacity or is unable to consent
Less complex non-emergency procedure with low risk of complications
Failure (ineffective pain relief)
Local anaesthetic toxicity
Aseptic non-touch technique
PPE: sterile gloves, sterile drape, sterile US cover and gel
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
Supine position with the affected limb slightly abducted and externally rotated if possible.
Lignocaine 1% 5ml for skin anaesthesia
Ropivacaine 0.375% 40ml (3mg/kg maximum), or
Bupivacaine 0.25% 40ml (2mg/kg maximum)
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
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)
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
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
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
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.
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
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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.