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Improving the success of the fascia iliaca compartment block

Last post 15 Sep 2013, 9:56 PM by Desire Onwochei. 0 replies.
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  •  15 Sep 2013, 9:56 PM 1478

    Improving the success of the fascia iliaca compartment block

    We wish to congratulate Newman et al [1] on their recent article regarding the relative merits of femoral nerve block (using a nerve stimulator) compared with a blind fascia iliaca compartment block. However, we would like to raise some issues.

    Whilst the nerve stimulator-assisted femoral nerve block has a reasonably reliable end point, the same cannot be said for the blind “double pop” technique for locating the fascia iliaca. In fact, ultrasound scanning of the inguinal region reveals various fascial planes. Hence, relying on the “double pop” felt during passage through the presumed fascia lata and fascia iliaca could lead to a substantial degree of error. Dolan et al [2] demonstrated that using ultrasound instead of the blind “double pop” technique increased the number of patients with complete loss of sensation in the lateral, anterior and medial thigh areas from 47% to 82%.

    Recently, an ultrasound-guided supra-inguinal approach based on cadaveric studies has been described and evaluated [3]. This technique has the advantage of direct visualisation of local anaesthetic within the fascia iliaca compartment and as it spreads more proximally, thereby increasing the possibility of blocking the lateral cutaneous nerve and some femoral nerve branches before they leave the plane. We speculate, therefore, whether the results obtained by Newman et al would have been different had ultrasound been used to assist location of the fascia iliaca compartment.

    The National Institute for Health and Care Excellence (NICE) guidance [4] for management of proximal femoral fracture states that pharmacological therapy for pain should be used first and consideration given to nerve blocks as a second line approach. We believe this needs to be revised. Previous correspondence by Funnell and Ford [5] has questioned this delayed approach and lack of importance placed on early nerve blockade, as well as identifying the harmful effects of excessive sedation arising from opioid analgesics if such a strategy is followed. They suggest the early administration of regional blockade, immediately following radiographic confirmation in the emergency department. Indeed, this is a technique that has been adopted by emergency departments with enthusiasm and success [6]. The excellent analgesia provided by early regional block may avoid the need for opioid analgesics and prevent the multitude of complications associated with them in an elderly population. This is a strategy we strongly advocate.

    We do recognise that use of ultrasound initially has both time and cost implications. It increases workloads for the emergency department, the anaesthetists who perform the block and nursing staff who subsequently monitor the patient. However, this initial investment may well prove effective in terms of faster recovery and reduced perioperative complications.

    I. Lambert

    D. Onwochei

    A. Dada

    Medway NHS Trust

    Gillingham, UK.

    Email: desire@doctors.org.uk

    No external funding and no competing interests declared. 

    References.

    1. 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 2013; 68: 899-903

    2. Dolan J, Williams A, Murney E, Smith M, Kenny GN. Ultrasound guided fascia iliaca block: a comparison with the loss of resistance technique. Regional Anaesthesia and Pain Medicine 2008; 33: 526-31

    3. Hebbard P, Ivanusic J, Sha S. Ultrasound guided supra-inguinal fascia iliaca block: a cadaveric evaluation of a novel approach. Anaesthesia 2011; 66: 300-5

    4. National Clinical Guideline Centre. The management of hip fractures in adults. 2011. http://guidance.nice.org.uk/CG124 (accessed 16/09/2013)

    5. Funnell A, Ford S. Fascia iliaca blocks for proximal femoral fractures. Anaesthesia 2012; 67: 673-4

    6. Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. Journal of Emergency Medicine 2012; 43:692-7

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