A Longitudinal Supra-Inguinal Fascia Iliaca Compartment Block Reduces Morphine Consumption After Total Hip Arthroplasty. Reg Anesth Pain Med. 2017;42:327-333. [PMID: 28059869 DOI: 10.1097/aap.0000000000000543]

Fibrous configuration of the fascia iliaca compartment: An epoxy sheet plastination and confocal microscopy study

Background and Objectives: The underlying anatomical mechanism of the ultrasound-guided fascia iliaca compartment (FIC) block for anaesthesia and analgesia in the lower limb has not been illuminated and numerous variations were attempted to achieve an optimal needle placement. This study aimed to define the fibrous configuration of the FIC. Methods: A total of 46 adult cadavers were studied using dissection, latex injection, epoxy sheet plastination and confocal microscopy. Results: (1) The fascia iliaca originated from the peripheral fascicular aponeurotic sheet of the iliopsoas. (2) The FIC was a funnel-shaped adipose space between the fascia iliaca and the epimysium of the iliopsoas, had a superior and an inferior opening and contained the femoral and lateral femoral cutaneous nerves but not obturator nerve. (3) The estimated volume of the FIC in the cadavers was about 23 mls, of which about one third was below the level of the anterior superior iliac spine. Conclusions: This study revealed that the fascia iliaca was aponeurotic and may be less permeable for the local anesthetics. Conclusions: The FIC contained only the femoral and lateral femoral cutaneous nerves and communicated with the extraperitoneal space and femoral triangle adipose space via its superior and inferior opening, respectively.

Pharmacokinetics of ropivacaine in elderly patients receiving fascia iliaca compartment block

Local anesthetic of ropivacaine was demonstrated to reduce the postoperative pain in elderly patients. This study investigated the pharmacokinetics of ropivacaine at different concentrations in elderly patients subjected to fascia iliaca compartment block. Forty patients with femoral neck fracture at American Society of Anesthesiologists (ASA) I-II status, undergoing fascia iliaca compartment block (FICB) were randomized to two groups receiving 0.7 ml/kg of solution containing 0.375% ropivacaine (group L) or 0.5% ropivacaine (group H). Samples of venous blood were obtained immediately at different time points after FICB, and the total and free plasma concentrations of ropivacaine were measured by liquid chromatography-electrospray ionization-tandem mass spectrometry (LC-ESI-MS/MS). Statistical analysis was carried out using a pharmacokinetic calculation program (DAS 3.0). Visual Analogue Scale (VAS) scores were significantly decreased after FICB in both groups, and VAS score in group H was lower compared with group L. The total maximum plasma concentration (C_max) and the free C_max of ropivacaine in group H was higher than that in group L (P<0.05). The decrease of the total and free plasma concentration was operation time-dependent. Neither group showed signs of central nervous system and circulatory system toxicity. On the basis of these results, the concentrations of 0.375 and 0.5% ropivacaine held an efficiently analgesic effect for FICB, suggesting that ropivacaine can be employed in analgesic therapy. However, both concentrations have a potentially theoretical risk of local anesthetics poisoning, suggesting that a lower concentration may be a safer option for a single large volume of FICB.

Peripheral nerve blocks for postoperative analgesia: From traditional unencapsulated local anesthetic to liposomes, cryoneurolysis and peripheral nerve stimulation

Peripheral nerve blocks (PNBs) using local anesthetics either via single injection or continuous perineural catheter have been the mainstay for regional anesthesia and are a vital component of postoperative multimodal opioid-sparing pain management. There are some limitations to PNBs, however, mainly its limited duration of action, but also risk of catheter-associated infection and dislodgements. Furthermore, local anesthetic-based blocks can induce sensory deficits and motor weakness, possibly increasing the risk of falling and/or decreasing the ability to participate in postoperative rehabilitation. In this review, we first discuss various local anesthetic-based PNB techniques for major surgery and then review newer modalities, including liposome bupivacaine, cryoanalgesia, and peripheral nerve stimulation; all of which may offer advantages over single and continuous local anesthetic-based PNBs.

Fascia iliaca block in the emergency department for hip fracture: a randomized, controlled, double-blind trial

BACKGROUND

Hip fracture causes moderate to severe pain and while fascia iliaca block has been reported to provide analgesic benefit, most previous trials were unblinded, with subsequent high risks of performance, selection and detection biases. In this randomized, control double-blind trial, we tested the hypothesis that a fascia iliaca block provides effective analgesia for patients suffering from hip fracture.

METHODS

Thirty ASA I-III hip fracture patients over 70 years old, who received prehospital morphine, were randomized to receive either a fascia iliaca block using 30 ml of bupivacaine 0.5% with epinephrine 1:200,000 or a sham injection with normal saline. The fascia iliaca block was administered by emergency medicine physicians trained to perform an anatomic landmark-based technique. The primary outcome was the comparison between groups of the longitudinal pain score profiles at rest over the first 45 min following the procedure (numeric rating scale, 0-10). Secondary outcomes included the longitudinal pain score profiles on movement and the comparison over 4 h, 8 h, 12 h, and 24 h after the procedure, along with cumulative intravenous morphine consumption at 24 h.

RESULTS

At baseline, the fascia iliaca group had a lower mean pain score than the sham injection group, both at rest (difference = - 0.9, 95%CI [- 2.4, 0.5]) and on movement (difference = - 0.9, 95%CI [- 2.7; 0.9]). These differences remained 45 min after the procedure and the two longitudinal pain score profiles were parallel both for patients at rest and on movement (test of parallelism for patients at rest p = 0.53 and on movement p = 0.45). The same parallel change in pain scores over time was observed over 24 h of follow-up (test of parallelism for patients at rest p = 0.82 and on movement p = 0.12). These results were confirmed after adjustment for gender, ASA score, and cumulative sums of intravenous morphine received pre-procedure and during-follow-up. In addition, there was no difference between the two groups in total cumulative intravenous morphine consumption at 24 h.

CONCLUSION

Fascia iliaca block following anatomic landmarks may not provide supplementary analgesia for patients suffering from hip fracture, when low pain scores are reported after prehospital morphine. Additional larger trials will help reach definitive conclusion.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov - NCT02433548 . The study was registered retrospectively.

ULTRASOUND SKILLS IN LOWER EXTREMITY TRAUMATOLOGY AND ORTHOPEDICS - REGIONAL ANESTHESIA AND BEYOND

During the last two decades ultrasound guidance has been established as an invaluable tool for performing peripheral nerve blocks. Ultrasound guidance reduces block performance time, volume of local anesthetic, risk of intravascular injection and need for opioid rescue analgesia compared to landmark based and neurostimulator guided techniques. The use of ultrasound guidance must not be understood as a surrogate to, but should complement a thorough understanding of anatomy. The purpose of this overview is to present ultrasound guided techniques for performing basic lower extremity blocks, as well as to discuss more recent trends in providing regional analgesia for patients undergoing lower extremity surgery.

Applications and critical evaluation of fascia iliaca compartment block and quadratus lumborum block for orthopedic procedures

Anterior section of the hip joint capsule is innervated by femoral nerve and obturator nerve, and posterior section is innervated by the nerve to quadratus femoris muscle and occasionally by the superior gluteal (posterolateral region) and sciatic nerve (posterosuperior region). One of the regional anesthesia options for hip surgery is the fascia iliaca compartment block (FICB) that affects nerves important for hip innervation and sensory innervation of the thigh - femoral, obturator and lateral femoral cutaneous nerve. FICB can be easily performed and is often a good solution for management of hip fractures in emergency departments. Its use reduces morphine pre-operative requirement for patients with femoral neck fractures and can also be indicated for hip arthroplasty, hip arthroscopy and burn management of the region. Quadratus lumborum block (QLB) is a block of the posterior abdominal wall performed exclusively under ultrasound guidance, with still unclarified mechanism of action. When considering hip surgery and postoperative management, the anterior QLB has shown to reduce lengthy hospital stay and opioid use, it improves perioperative analgesia in patients undergoing hip and proximal femoral surgery compared to standard intravenous analgesia regimen, provides early and rapid pain relief and allows early ambulation, thus preventing deep vein thrombosis and thromboembolic complications etc. However, some nerve branches responsible for innervation of the hip joint are not affected by QLB, which has to be taken into consideration. QLB has shown potential for use in hip surgery and perioperative pain management, but still needs to be validated as a reliable treatment approach.

Supra-inguinal injection for fascia iliaca compartment block results in more consistent spread towards the lumbar plexus than an infra-inguinal injection: a volunteer study

BACKGROUND AND OBJECTIVES

Lumbar plexus block has been used to provide postoperative analgesia after lower limb surgery. The fascia iliaca compartment block (FICB) has been proposed as an anterior approach of the lumbar plexus targeting the femoral, obturator and lateral femoral cutaneous nerve. However, both radiological and clinical evidence demonstrated that an infra-inguinal approach to the fascia iliaca compartment does not reliably block the three target nerves.We hypothesized that a supra-inguinal approach of the fascia iliaca compartment results in a more consistent block of the three target nerves than an infra-inguinal approach.

METHODS

We performed a randomized controlled, double-blind trial in 10 healthy volunteers. Both an infra-inguinal FICB (I-FICB) and a supra-inguinal FICB (S-FICB) were performed on the left or the right side in each volunteer. Forty milliliters of lidocaine 0.5% was injected with each approach. Sensory and motor block and spread of local anesthetics (LA) on MRI were assessed.

RESULTS

After an S-FICB, 80% of the volunteers had a complete sensory block of the medial, anterior and lateral region of the thigh, compared with 30% after an I-FICB (p=0.035). There was an insignificant effect on motor function with both approaches. After an S-FICB, in 8 out of 10 volunteers there was spread of LA in the expected anatomic location of the obturator nerve on MRI compared with 1 out of 10 volunteers after an I-FICB (p=0.0017). The cranial spread of LA after an S-FICB on MRI was higher than after an I-FICB (p=0.007), whereas there was a more caudal spread of LA on MRI after an I-FICB than after an S-FICB (p=0.005).

CONCLUSIONS

An S-FICB produces a more complete sensory block of the medial, anterior and lateral region of the thigh, compared with an I-FICB. Our study demonstrates that an S-FICB with 40 mL of LA more reliably spreads LA to the anatomical location of the three target nerves of the lumbar plexus on MRI than an I-FICB. An S-FICB also leads to a more consistent spread in a cranial direction under the fascia iliaca and around the psoas muscle.

CLINICAL TRIAL REGISTRATION

This work was registered with the European clinical trial registry: Identifier Eudra CT 2015-004607-24.

Ultrasound-guided suprainguinal fascia iliaca compartment block versus periarticular infiltration for pain management after total hip arthroplasty: a randomized controlled trial

Background and objectives

Fascia iliaca compartment block (FICB) has been shown to provide excellent pain relief in patients undergoing total hip arthroplasty (THA). However, the analgesic efficacy of FICB, in comparison with periarticular infiltration (PAI) for THA, has not been evaluated. This randomized, controlled, observer-blinded study was designed to compare suprainguinal FICB (SFICB) with PAI in patients undergoing THA via posterior approach.

Methods

After institutional review board approval, 60 consenting patients scheduled for elective THA were randomized to one of two groups: ultrasound-guided SFICB block or PAI. The local anesthetic solution for both the groups included 60 mL ropivacaine 300 mg and epinephrine 150 µg. The remaining aspects of perioperative care, including general anesthetic and non-opioid multimodal analgesic techniques, were standardized. An investigator blinded to group allocation documented pain scores at rest and with movement and supplemental opioid requirements at various time points. Patients were evaluated for sensory changes and quadriceps weakness in the operated extremity.

Results

There were no differences between the groups with respect to demographics, intraoperative opioid use, duration of surgery, recovery room stay, nausea scores, need for rescue antiemetics, time to ambulation and time to discharge readiness as well as 48 hours postoperative opioid requirements. The pain scores at rest and with movement also were similar at all time points. Significantly more patients in the SFICB group experienced muscle weakness at 6 hours after surgery.

Conclusions

Under the circumstances of our study, in patients undergoing THA, SFICB provided the similar pain relief compared with PAI, but was associated with muscle weakness at 6 hours postoperatively.

Trial registration number

NCT02658240.

The efficacy of fascia iliaca compartment block for pain control after total hip arthroplasty: a meta-analysis

Purpose

Fascia iliaca compartment block (FICB) provides an analgesic option for total hip arthroplasty (THA) patients. The evidence supporting FICB is still not well established. The purpose of this meta-analysis was to assess FICB for pain control in THA patients.

Methods

PubMed, Embase, Cochrane Library, and Chinese Wanfang database were interrogated from their inceptions to December 15, 2018. We included randomized controlled studies reported as full text, those published as abstracts only, and unpublished data, if available. Data were independently extracted by two reviewers and synthesized using a random-effects model or fixed-effects model according to the heterogeneity.

Results

A total of eight RCTs were finally included for meta-analysis. Compared with placebo, FICB could significantly reduce VAS pain scores at 1–8 h (WMD = − 0.78, 95% CI [− 1.01, − 0.56], P = 0.000), 12 h (WMD = − 0.69, 95% CI [− 1.22, − 0.16], P = 0.011), and 24 h (WMD = − 0.46, 95% CI [− 0.89, − 0.02], P = 0.039). Compared with the control group, FICB could significantly decrease the occurrence of nausea and length of hospital stay (P < 0.05). There was no significant difference between the VAS pain score at 48 h and risk of fall between the FICB and the control groups (P > 0.05).

Conclusions

FICB could be used to effectively reduce pain intensity up to 24 h, total morphine consumption, and length of hospital stay in THA patients. Optimal strategies of FICB need to be studied in the future.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-1053-1) contains supplementary material, which is available to authorized users.

Lower extremity regional anesthesia: essentials of our current understanding

The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine's ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.

The effect of the volume of supra-inguinal injected solution on the spread of the injectate under the fascia iliaca: a preliminary study

The fascia iliaca compartment is the compartment confined by the fascia iliaca (FI) and a muscular layer formed by the iliac- and psoas muscle. This compartment creates a virtual tunnel that contains the femoral nerve (FN), the obturator nerve (ON), and the lateral femoral cutaneous nerve (LFCN) of the lumbar plexus. In this pilot study, we aimed to determine the suggested volume needed to reach the three target nerves of the lumbar plexus (FN, ON, and LFCN) with a single-injection ultrasound-guided supra-inguinal fascia iliaca compartment (S-FICB). A computer tomography (CT scan)-guided step-up/step-down sequence was used to determine the suggested injection volume to target all three nerves. Subsequently, an anatomist blinded for the injected volume and CT findings, dissected the cadavers, and evaluated the spread of dye underneath the fascia iliaca. In total, seven pelvic areas of four cadavers were evaluated on CT scan and dissected. Distribution of dye underneath the FI in relation to the FN, ON, and the LFCN was recorded in all dissected cadavers. Combining CT and dissection findings, the suggested volume to reach the FN, ON, and LFCN with an S-FICB was 40 mL.

Preoperative Fascia Iliaca Block Does Not Improve Analgesia after Arthroscopic Hip Surgery, but Causes Quadriceps Muscles Weakness

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Ambulatory hip arthroscopy is associated with postoperative pain routinely requiring opioid analgesia. The potential role of peripheral nerve blocks for pain control after hip arthroscopy is controversial. This trial investigated whether a preoperative fascia iliaca block improves postoperative analgesia.

Methods

In a prospective, double-blinded trial, 80 patients scheduled for hip arthroscopy were randomized to receive a preoperative fascia iliaca block with 40 ml ropivacaine 0.2% or saline. Patients also received an intraarticular injection of 10-ml ropivacaine 0.2% at procedure end. Primary study endpoint was highest pain score reported in the recovery room; other study endpoints were pain scores and opioid use 24 h after surgery. Additionally, quadriceps strength was measured to identify leg weakness.

Results

The analysis included 78 patients. Highest pain scores in the recovery room were similar in the block group (6 ± 2) versus placebo group (7 ± 2), difference: −0.2 (95% CI, −1.1 to 0.7), as was opioid use (intravenous morphine equivalent dose: 15 ± 7mg [block] vs. 16 ± 9 mg [placebo]). Once discharged home, patients experienced similar pain and opioid use (13 ± 7 mg [block] vs. 12 ± 8 mg [placebo]) in the 24 h after surgery. The fascia iliaca block resulted in noticeable quadriceps weakness. There were four postoperative falls in the block group versus one fall in the placebo group.

Conclusions

Preoperative fascia iliaca blockade in addition to intraarticular local anesthetic injection did not improve pain control after hip arthroscopy but did result in quadriceps weakness, which may contribute to an increased fall risk. Routine use of this block cannot be recommended in this patient population.

Update on Selective Regional Analgesia for Hip Surgery Patients

In hip surgery, regional anesthesia offers benefits in pain management and recovery. There are a wide range of regional analgesic options; none have shown to be superior. Lumbar plexus block, femoral nerve block, and fascia iliaca block are the most supported by published literature. Other techniques, such as selective obturator and/or lateral femoral cutaneous nerve blocks, represent alternatives. Newer approaches, such as quadratus lumborum block and local infiltration analgesia, require rigorous studies. To realize long-term outcome benefits, postoperative regional analgesia must be tailored to the individual patient and last longer.

Fascia iliaca compartment block versus no block for pain control after lower limb surgery: a meta-analysis

Background

The analgesic effect of fascia iliaca compartment block (FICB) versus no block (NB) after lower limb surgery (LLS) is still controversial, so we performed this meta-analysis.

Materials and methods

By searching the PubMed, Embase and the Cochrane Library (last update by July 20, 2017), randomized controlled trials comparing the analgesic effect of FICB versus NB in patients receiving LLS were identified. The primary outcome was the pain scores at 4, 12, and 24 h after LLS. The dosage of morphine at 24 h was also collected. The side effect of anesthesia was assessed according to the occurrence rate of postoperative nausea and vomiting.

Results

Data from 7 clinical trials that included 508 patients were summarized. The results showed that patients receiving FICB had lower pain scores at 4 h (mean difference [MD]=−1.17; 95% CI=−2.30 to −0.05; P=0.041), 12 h (MD=−0.41; 95% CI=−0.76 to −0.05; P=0.026) and 24 h (MD=−0.96; 95% CI=−1.77 to −0.15; P=0.020) after LLS. Besides, FICB could reduce the dosage of morphine at 24 h (MD=−2.06; 95% CI=−3.82 to −0.30; P=0.022) and the incidence of postoperative nausea and vomiting (relative risk rate=0.44, 95% CI=0.24–0.80, P=0.008).

Conclusion

Compared with NB, FICB is an effective and safe method for alleviating the pain after LLS. More high-quality randomized controlled trials are needed to confirm this finding.

Technical success of the ultrasound-guided supra-inguinal fascia iliaca compartment block in older children and adolescents for hip arthroscopy

BACKGROUND

Hip arthroscopic surgery is performed on older pediatric patients. Fascia iliaca compartment block has proven efficacy in providing analgesia following hip surgery and can be performed with target location of local anesthetic below or above the inguinal ligament. The reported success of ultrasound-guided infra-inguinal fascia iliaca compartment block is lower when compared to traditional landmark technique, while the reliability of supra-inguinal fascia iliaca compartment block is unreported.

AIM

The primary aim was to report the results in obtaining sensory changes in the distribution of the femoral and lateral femoral cutaneous nerves following supra-inguinal fascia iliaca compartment block in patients undergoing arthroscopic hip surgery. Secondary outcomes are the ability to find echogenic landmarks and to report pain scores and opioid consumption.

METHODS

We reviewed the electronic medical record and regional anesthesia database of patients receiving ultrasound-guided fascia iliaca compartment block for arthroscopic hip surgery. Sensory changes to the femoral and lateral femoral cutaneous nerves were determined. Identification of echogenic landmarks was quantified. Pain scores and opioid consumption were determined.

RESULTS

Seventeen patients of mean age 15.4 years old (SD 1.3; range 13-17 years) were included. Sensory changes to both the femoral and lateral femoral cutaneous nerves occurred in 94% of patients (95% CI: 82%-100%). The average volume of ropivacaine 0.2% was 0.53 mL/Kg (SD 0.11 mL/Kg). Echogenic landmarks were identified in all patients. Pain scores and opioid consumption were generally low.

CONCLUSION

A supra-inguinal location for the deposition of local anesthetic when performing fascia iliaca nerve block for hip surgery is reliable in anesthetizing the femoral and lateral femoral cutaneous nerves and should encourage investigation into the clinical efficacy.

The efficiency and safety of fascia iliaca block for pain control after total joint arthroplasty: A meta-analysis

BACKGROUND

This meta-analysis aimed to perform a meta-analysis including randomized controlled trials (RCTs) to assess the efficiency and safety of fascia iliaca block (FIB) for pain control in patients undergoing total joint arthroplasty (TJA).

METHODS

A systematic search was performed in Medline (1966-2017.03), PubMed (1966-2017.03), Embase (1980-2017.03), ScienceDirect (1985-2017.03) and the Cochrane Library. Study evaluated the efficiency and safety of FIB in TJA was selected. Meta-analysis was performed using Stata 11.0 software.

RESULTS

Five randomized controlled trials (RCTs) including 270 patients met the inclusion criteria. The present meta-analysis indicated that there were significant differences between groups in terms of visual analog scale (VAS) score at 12 hours (SMD = -0.544, 95% CI: -0.806 to -0.281, P = .000) and 24 hours (SMD = -0.519, 95% CI: -0.764 to -0.273, P = .000), morphine equivalent consumption at 12 hours (SMD = -0.895, 95% CI: -1.164 to -0.626, P = .000) and 24 hours (SMD = -0.548, 95% CI:-0.793 to -0.303, P = .000). In addition, fewer adverse side effect was identified in FIB groups (RD = -0.139, 95% CI: -0.243 to -0.034, P = .009).

CONCLUSION

The application of fascia iliaca block could significantly reduce VAS scores and morphine consumption at 12 and 24 hours following total knee and hip arthroplasty. In addition, there were fewer adverse effects in FIB groups. Due to the limited quality of the evidence currently available, higher quality RCTs are required.