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Fascia iliaca compartment block: a short how-to guide

Authors:
  • College of Remote and Offshore Medicine

Abstract

The fascia iliaca compartment block (FICB) aims to provide anaesthesia and analgesia to the anterior compartment of the thigh, thereby providing analgesia for fractures to the femur and neck of femur, as well as potentially for soft tissue injures to this area. It does this by interrupting the conduction of nerve impulses by the femoral nerve and lateral cutaneous nerve of the thigh. An FICB does not provide analgesia or anaesthesia to the distal leg below the knee, which is supplied by the sciatic nerve, nor to the medial aspect of the thigh, which is supplied by the obturator nerve.
154 Vol 11 No 4 Journal of Paramedic Practice
Comment
© 2019 MA Healthcare Ltd
Fascia iliaca compartment
block: a short how-to guide
The fascia iliaca compartment
block (FICB) aims to provide
anaesthesia and analgesia
to the anterior compartment of the
thigh, thereby providing analgesia for
fractures to the femur and neck of
femur, as well as potentially for soft-
tissue injures to this area.
It does this by interrupting the
conduction of nerve impulses by the
femoral nerve and lateral cutaneous
nerve of the thigh. An FICB does not
provide analgesia or anaesthesia to
the distal leg below the knee, which
is supplied by the sciatic nerve, nor to
the medial aspect of the thigh, which is
supplied by the obturator nerve.
A short guide is presented to the
landmark approach to FICB, and the
choice of local anaesthetic volume to
be given by patient’s estimated weight.
The technique
FICB is a simple technique, and allows
a high quality of analgesia to be given
without the side effects of opiate
analgesia. FICB is the current gold
standard in the management of neck of
femur fractures with pain unresponsive
to intravenous opioids and paracetamol
(National Institute for Health and Care
Excellence (NICE), 2017). It is frequently
performed in emergency departments,
but has also been used as a prehospital
intervention by nurses and paramedics,
where it has been demonstrated to be
both safe and effective (Hards et al,
2018), without reducing on-scene times
(McRae et al, 2015).
The technique is easy to learn and
can be undertaken using a landmark
technique or with ultrasound guidance
(Chesters, et al, 2009). A sample
technique monograph is included
in Table1. Although point of care
ultrasound (PoCUS) is becoming more
commonplace in prehospital care and
paramedic practice across the country, it
is unlikely that PoCUS will be available
on all frontline ambulances in the near
future. Therefore, this article will focus
on the landmark technique, which
is still widely used. Use of FICB has
been shown to be associated with a
reduced need for opiate analgesia and
is likely to lead to more effective pain
relief, with fewer side effects, than oral
or injected analgesics (Fadhlillah and
Chan, 2017; Kassam et al, 2018). FICB is
also likely to lead to improved patient
outcomes (Callear and Shah, 2016),
including increasing a person’s chances
of returning home on discharge from
hospital (Bray and Collins, 2015).
Tom Mallinson, Prehospital & Rural Medicine Doctor, Critical Care Paramedic, NHS Western Isles, Stornoway, Outer Hebrides,
Scotland. Email for correspondence: tom.mallinson@nhs.net
Table 1. Technique monograph
Fascia iliaca compartment block
Indications
lFemoral fractures including fractures to the neck of femur
lSoft-tissue injuries to the anterolateral thigh
Side effects
lHaematoma formation
lBleeding
lNerve injury
lVascular injury
lLocal anaesthetic toxicity
lFailure (inadequate analgesia)
lAllergy/anaphylaxis
lApnoea as a result of previously administered opiates
Contraindications
lOverlying infection
lAllergy to local anaesthetics
lPatient refusal
lPrevious surgery to groin
lAnticoagulated or bleeding disorder
lAge under 18 years
Administration
Levobupivicaine 0.25%
Weight
25–35kg
>40kg
Volume (of 0.25% solution)
20ml
30ml
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Journal of Paramedic Practice Vol 11 No 4 155
Comment
© 2019 MA Healthcare Ltd
Landmark technique
The location for FICB must be
correctly identified to minimise risk of
complications. The first two important
landmarks are the anterior superior iliac
spine (ASIS) and the pubic tubercle
of the pelvis. These two points are
connected subcutaneously by the
inguinal ligament, the next important
landmark. The length of the inguinal
ligament needs to be divided into
thirds; this can be easily estimated
using the index and middle ngers of
each hand. From this point, the site
for injection is located 1–2cm distally
from the junction of the lateral and
middle third. The femoral artery can
be palpated medially to the puncture
site prior to undertaking the technique
to reassure the practitioner that their
chosen site is distant from the large
neuromuscular bundle in the thigh
(Figure1).
The point for injection can be marked
with pressure from the blunt end of
a needle or a needle cover before a
sterile area has been created. The area
surrounding the injection site is then
cleaned with 70% isopropyl alcohol
or chlorhexidine and allowed to dry
(this is especially important when
chlorhexidine is used, as it is a potent
neurotoxin). The skin can now be
anaesthetised with around 2ml of 1%
lidocaine if required.
A short bevelled or blunted needle
attached to the syringe holding the
levobupivicaine is now inserted
through the skin at a 90 angle. The
needle is advanced, producing two
palpable ‘pops’ as the needle perforates
the fascia lata and the fascia iliaca. After
advancing another 1–2mm, aspiration
is attempted to verify that the tip of
the needle is not within a blood vessel.
Once negative aspiration has been
observed, injection can begin. While
the procedure may feel uncomfortable,
there should be little resistance and
the patient should not experience pain
on injection. Once the volume desired
has been injected, remove the needle
and dispose of this safely, then apply
gentle pressure to the area for around
2minutes. Analgesia will become
apparent over the next 10–30minutes;
during this time, vital signs should be
monitored and the patient observed
for signs of local anaesthetic toxicity
(Box1).
Conclusion
FICB is a safe and effective means
of providing analgesia for injuries to
the anterolateral thigh or femur, and
although not currently a technique
widely used by paramedics within the
UK, it is certainly on the horizon for
specialist and advanced paramedics
nationwide. A short guide to the
technique has been presented here
for education and reference, although
this does not replace comprehensive
teaching and supervised practice to
achieve clinical competence. JPP
References
Bray H, Collins N. The effects of fascia iliac
compartment block for hip fractures on length
of hospital stay and discharge destination.
Emerg Med J. 2015; 32:985–986
Callear J, Shah K. Analgesia in hip fractures. Do
fascia-iliac blocks make any difference? BMJ
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w4147. https://doi.org/10.1136/bmjquality.
u210130.w4147
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management of hip fractures. Emerg Med J.
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compartment block for femoral bone fractures:
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Kassam AM, Gough AT, Davies J, Yarlagadda
R. Can we reduce morphine use in elderly,
proximal femoral fracture patients using
a fascia iliac block? Geriatric Nurs. 2018;
39(1):84–87
McRae PJ, Bendall JC, Madigan V, Middleton
PM. Paramedic-performed Fascia Iliaca
Compartment Block for femoral fractures: A
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Box 1. Signs and symptoms
of local anaesthesia toxicity
lSeizure
lPerioral tingling
lCardiac dysrhythmia
lLoss of consciousness
lCardiac arrest
The chosen site must be distant from the large neuromuscular bundle
in the thigh
©SARAH JANE PALMER FINE ART
Left middle finger
on right ASIS
Dividing distance from ASIS
to PT into thirds, using
index fingers
Right middle finger
on right PT
Downloaded from magonlinelibrary.com by Tom Mallinson on May 4, 2019.
... Several anesthetic drugs are used in the anesthesia process, which can cause side effects in some people. The anesthesiologist talks to the patient about the side effects that the patient may experience after anesthesia and inform the measures that should be taken to reduce these side effects [2][3][4][5]. Some of the complications of anesthesia that the patient may experience after regaining consciousness are feeling sick or nauseated, dizzy or weak, feeling cold or shivering, headache, itching, bruising and pain, difficulty urinating, and pain in different parts of the body. ...
... Some of the complications of anesthesia that the patient may experience after regaining consciousness are feeling sick or nauseated, dizzy or weak, feeling cold or shivering, headache, itching, bruising and pain, difficulty urinating, and pain in different parts of the body. Side effects of anesthesia usually do not remain for a long time in the body, but some can be treated if necessary [1,5]. If the patient experiences any of these side effects after the surgery, she must inform the nurse or the person in charge. ...
... Most people do not experience long-term side effects from anesthesia, but older people may have side effects that last more than a few days, including post-surgery delirium and post-surgery cognitive impairment. Some studies show that people over 60 are more susceptible to cognitive impairment after surgery [5,6]. In addition, Parkinson's disease, Alzheimer's disease, lung disease, heart disease, and stroke history increase the complications of anesthesia [2,5]. ...
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Introduction Femoral fractures are painful injuries frequently encountered by prehospital practitioners. Systemic opioids are commonly used to manage the pain after a femoral fracture; however, regional techniques for providing analgesia may provide superior targeted pain relief and reduce opioid requirements. Fascia Iliaca Compartment Block (FICB) has been described as inexpensive and does not require special skills or equipment to perform, giving it the potential to be a suitable prehospital intervention. Problem The purpose of this systematic review is to summarize published evidence on the prehospital use of FICB in patients of any age suffering femoral fractures; in particular, to investigate the effects of a prehospital FICB on pain scores and patient satisfaction, and to assess the feasibility and safety of a prehospital FICB, including the success rates, any delays to scene time, and any documented adverse effects. Methods A literature search of MEDLINE/PubMED, Embase, OVID, Scopus, the Cochrane Database, and Web of Science was conducted from January 1, 1989 through February 1, 2017. In addition, reference lists of review articles were reviewed and the contents pages of the British Journal of Anaesthesia (The Royal College of Anaesthetists [London, UK]; The College of Anaesthetists of Ireland [Dublin, Ireland]; and The Hong Kong College of Anaesthesiologists [Aberdeen, Hong Kong]) 2016 along with the journal Prehospital Emergency Care (National Association of Emergency Medical Service Physicians [Overland Park, Kansas USA]; National Association of State Emergency Medical Service Officials [Falls Church, Virginia USA]; National Association of Emergency Medical Service Educators [Pittsburgh, Pennsylvania USA]; and the National Association of Emergency Medical Technicians [Clinton, Mississippi USA]) 2016 were hand searched. Each study was evaluated for its quality and its validity and was assigned a level of evidence according to the Oxford Centre for Evidence-Based Medicine (OCEBM; Oxford, UK). Results Seven studies involving 699 patients were included (one randomized controlled trial [RCT], four prospective observational studies, one retrospective observational study, and one case report). Pain scores reduced after prehospital FICB across all studies, and some achieved a level of significance to support this. Out of a total of 254 prehospital FICBs, there was a success rate of 90% and only one adverse effect reported. Few studies have investigated the effects of prehospital FICB on patient satisfaction or scene time delays. Conclusions and Relevance The FICB is suitable for use in the prehospital environment for the management of femoral fractures. It has few adverse effects and can be performed with a high success rate by practitioners of any background. Studies suggest that FICB is a useful analgesic technique, although further research is required to investigate its effectiveness compared to systemic opioids. HardsM , BrewerA , BessantG , LahiriS . Efficacy of prehospital analgesia with Fascia Iliaca Compartment Block for femoral bone fractures: a systematic review . Prehosp Disaster Med . 2018 ; 33 ( 3 ): 299 - 307 .
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Proximal femoral fractures are becoming increasingly common with an ageing population. Many patients have multiple comorbidities increasing their risk of opiate complications. 40 consecutive patients presenting with a proximal femoral fracture to a trauma centre in the UK were given either a Fascia Iliaca Block (FIB) with oral analgesia or just oral analgesia to control their pre-operative pain. Numeric pain scores and morphine consumption were used as outcome measures. Patients receiving a FIB had significant reduction in their pain scores compared to patients only receiving oral pain relief. There was also a significant reduction in both the actual oral morphine taken and the renal calculated level of morphine products in the group receiving the FIB. Patients undergoing a FIB required almost 50 mg less oral morphine pre-operatively. Nerve blocks should be used routinely to help pre-operative pain in proximal femoral fracture patients and to reduce the amount of morphine products prescribed. This prevents potential opiate complications in a highly susceptible cohort of patients often suffering with impaired renal function as a co-morbidity.
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Femoral (thigh) fractures are an important clinical problem commonly encountered by paramedics. These injuries are painful, and the need for extrication and transport adds complexity to the management of this condition. Whereas traditional analgesia involves parenteral opioids, regional nerve blockade for femoral fractures have been demonstrated to be effective when performed by physicians. Regional peripheral nerve blockade performed by paramedics may be suitable in the prehospital setting. To examine the efficacy and feasibility of paramedic-performed fascia iliaca compartment block (FICB) for patients with suspected hip or femur fractures in the prehospital setting compared to intravenous morphine alone. Prior to treatment allocation, all patients received a loading dose of morphine intravenously, then received either 1) FICB using lidocaine with epinephrine; or 2) standard care (further intravenous morphine only) in this nonblinded, randomized control trial. Participants rated their pain using a standard 11-point verbal numerical rating scale prior to and 15 min after receiving the allocated treatment. Secondary outcomes included effectiveness at other time points and incidence of adverse effects. We analyzed 11 and 13 patients in the FICB and standard care groups, respectively. Patients treated with FICB had a greater reduction in their median pain score than patients in the standard care group (50% vs. 22%, p = 0.025) after 15 min. In the FICB group, median pain scores decreased by 5 (interquartile range 4-6), compared to 2 (interquartile range 0-4) in the standard care group. The FICB procedure did not significantly impact on scene times. No immediately obvious adverse events were noted in the 11 participants who received FICB from paramedics. The study suggests that FICB can be performed by trained paramedics for patients with suspected femoral fractures. Copyright © 2015 Elsevier Inc. All rights reserved.