excalibur

Member
10+ Year Member
Oct 15, 2005
655
7
Status
Attending Physician
Have been thinking about this for a while, and I have done several searches on this site and searches in the anesthesia literature.

What prompted my thoughts was a pt many of us have seen before. A 90 year old demented, DNR, nursing home pt, with multiple co-morbidities who presents with femoral neck fracture and is booked for OR.

In thinking about alternatives from GA for this patient, epidural and spinal are options, but positioning this patient with hip fx for those procedures could be a nightmare, and then the hope is that her spine is not so stricken with degenerative arthritis that you could hit your target.

This started me on the search for some other regional techniques, and preferably techniques that could be done in the supine position to avoid having the pt painfully sit up or lie on their side.

This is where I discovered the Fascia Iliaca Compartment Block (FICB), which I have yet to perform, but with a little bit of reading and seeing some videos, it seems easy enough. It appears that this blocks ultimately results in the effects of a lumbar plexus block, but avoids the complications inherent to LP block like retroperitoneal hemorrhage, aortic or kidney injury, epidural spread, etc. Plus with FICB, you can do it supine, and your target is much nearer to needle point of entry. It just ssems that FICB is an anterior and much safer approach to get the effects of LP block. I have seen the ultrasound views for FICB, and it seems like it would be a breeze with U/S. Several articles and posts from site members have stated that this block is excellent for perioperative analgesia, but the key is that a large amount of volume is required (40-50 mL). Furthermore, the literature supports that this technique reliably blocks the lateral femoral cutaneous nerve and femoral nerve as compared to the traditional Winnie "3 in 1 block" which does not reliably block the lateral femoral cutaneous nerve.

Some posters have stated that this block is super easy and tremendously reduces opioid requirement. One post i read stated that they did a hip with this block and only 100 mcg of fentanyl for the case.

So I first thought well if FICB results in a LP block with reliably blocking the two most important nerves (femoral and lateral femoral cutaneous nerves), why not inject 40-50 mL of concentrated LA to provide surgical anesthesia.

So question 1:
Shouldn't 45 mL of Ropivacaine 0.5% in a FICB maybe accompanied by light sedation be adequate to repair a fractured hip??

OK, if the answer to question 1 is "No, that technique is not sufficient anesthesia for surgical anesthesia", let's think why. Hopefully, I hear from people who have just tried that, but my theory would be that you also need to block the S1 and S2 roots or simply the sciatic nerve.

I searched for responses on my next question

Question 2:
Would FICB + sciatic nerve block be adequate for hip surgery?
-I found a poster who stated that he would frequently do hips with LP block and sciatic block with nothing else. This poster stated he would use 20 mL of 0.75% for each block. Although I feel the amount of LA used here may possibly exceed the recommended maximum dose for local toxicity, it appears that hips can be done with a LP block and sciatic nerve block with no further sedation.

If FICB indeed replicates the effects of LP block, wouldn't it make sense to just do the much safer FICB than LP block? And if FICB + sciatic nerve block is adequate for hip surgery, then I pose question 3...

Question 3:
Would FICB + ANTERIOR SCIATIC NERVE BLOCK be adequate for repair of femoral neck surgery?

If so, then both blocks could be done with pt supine right on the anterior thigh. In trying to keep Ropivacaine dose to 225 mg what about 42 mL of Ropivacaine 0.4% for FICB + 14 mL for anterior sciatic block? Also I feel that the concentration for the sciatic block could be reduced given that the local would be injected right next to the nerve and the sciatic would not be as main of a player in the hip surgery as femoral and lateral cutaneous nerve (or in essence the lumbar roots that are bathed from FICB), so another option could be 45 mL of Ropivacaine 0.4% for FICB plus 18 mL of Ropivacaine 0.25% for sciatic block.

Thoughts?? Am I crazy or could a hip be done with two blocks on the thigh with patient in supine position the entire time?
 

B-Bone

Attending
15+ Year Member
Jun 22, 2004
505
471
Status
Attending Physician
90 yo demented lady + 10 mg ketamine = put 'em in whatever position you want. place spinal. done.
 
OP
excalibur

excalibur

Member
10+ Year Member
Oct 15, 2005
655
7
Status
Attending Physician
90 yo demented lady + 10 mg ketamine = put 'em in whatever position you want. place spinal. done.
I understand the case can be done under spinal or other ways. My question is could the case be done under the technique I described.
 

Oggg

ASA Member
May 2, 2011
962
21
Status
Q1: I believe the sciatic nerve innervates part of the hip joint and proximal femur, so FICB is not enough for surgical anesthesia. The obturator also supplies part of the hip joint (can't remember if it does prox femur as well), and the chance of obturator block is low (40%?) with FICB.
Q2: you need to block the sciatic very high up in the buttocks to get the nerves that go to the hip and prox femur. Also you may miss obturator. Also FICB is hella slow, another reason it's bad for surgical anesthesia. Granted, there are some case reports of femoral fx surgery under lumbar plexus and high sciatic and light sedation in some sick patients.
3. You might get lucky and get proximal spread of local anesthetic up the sciatic, but I'd guess the chances are low. You really need a parasacral or Labat approach.

FICB is easy and fast and doable under GA. It's also slow and not that reliable. It takes a lot of volume so it's hard to get surgical anesthesia without going over the toxic limits.

The posterior lumbar plexus block + parasacral sciatic block is shown in a YouTube video, I think yrpeng. Nerve stim only. I've heard some ppl doing LPB parasacral sciatic then SAB. Great practice and glory if you can do this in academia. In PP, go with straight GA or SAB, or toss in a light FICB (+GA/SAB) for some extra reimbursement. Hips don't hurt so much once they're reduced. I'd use 40-50cc of 0.2-0.25%bupiv.
 
OP
excalibur

excalibur

Member
10+ Year Member
Oct 15, 2005
655
7
Status
Attending Physician
I have gone over the anatomy of the innervation of the hip joint and it seems that...

Anteriorly
the main articular branches are from obturator nerve and femoral nerve

Posteriorly
the main articular branches are from nerve to quadratus femoris and superior gluteal nerve, with occassionaly a branch coming from the sciatic nerve.

I can see how anterior sciatic block now would basically be too low for the joint and if anything might help only with sensory to proximal shaft of femur. Ultimately though anterior sciatic block would not help much in hip surgery

The nerves mentioned above, however, have mainly lumbar nerve roots like L2 to L5/S1. So if enough local is injected in a FICB, like 50 mL, and light pressure is held on antherior thigh promoting cephalad spread, is it feasible that there would be enough local anesthetic to reach the lumbar roots of the plexus? Does the compartment under the fasica iliaca where we would inject the local spread all the way to the roots?
 

BLADEMDA

ASA Member
10+ Year Member
Apr 22, 2007
17,246
3,476
Southeast
Status
Attending Physician
Q1: I believe the sciatic nerve innervates part of the hip joint and proximal femur, so FICB is not enough for surgical anesthesia. The obturator also supplies part of the hip joint (can't remember if it does prox femur as well), and the chance of obturator block is low (40%?) with FICB.
Q2: you need to block the sciatic very high up in the buttocks to get the nerves that go to the hip and prox femur. Also you may miss obturator. Also FICB is hella slow, another reason it's bad for surgical anesthesia. Granted, there are some case reports of femoral fx surgery under lumbar plexus and high sciatic and light sedation in some sick patients.
3. You might get lucky and get proximal spread of local anesthetic up the sciatic, but I'd guess the chances are low. You really need a parasacral or Labat approach.

FICB is easy and fast and doable under GA. It's also slow and not that reliable. It takes a lot of volume so it's hard to get surgical anesthesia without going over the toxic limits.

The posterior lumbar plexus block + parasacral sciatic block is shown in a YouTube video, I think yrpeng. Nerve stim only. I've heard some ppl doing LPB parasacral sciatic then SAB. Great practice and glory if you can do this in academia. In PP, go with straight GA or SAB, or toss in a light FICB (+GA/SAB) for some extra reimbursement. Hips don't hurt so much once they're reduced. I'd use 40-50cc of 0.2-0.25%bupiv.
Correct. We have discussed this in the private forum. Blocks miss L1 which may need a separate paraverterbal injection.

I use propofol 20 mg IV and turn the patient since they rarely weigh anything. Then, 8 mg of Bup (hyperbaric is fine).

Complaints of pain post op are minimal with a Troch nail in this age group.
 

pgg

Laugh at me, will they?
Administrator
10+ Year Member
Dec 15, 2005
12,160
8,192
Home Again
Status
Attending Physician
I put in FI blocks for almost all of my hip fractures, but the primary anesthetic is still GA or spinal. Occasionally I'll get a troch nail patient who gets GA + FI and has zero pain afterwards despite nothing more than ~50mcg fentanyl for the ETT or no narcotic (LMA), leading me to think that maybe I could get away with FI only for those cases. But even then setup time and reliability are big questions.

For anything more than a troch nail, even in the best case a FI block is almost certain to miss at least the posterior 1/3 of the acetabulum so I wouldn't have any hope of it being adequate as the sole anesthetic. A sciatic block is going to be too low, and if you're going to supplement with paravertebrals like Blade mentioned, what's the point of all the hoop-jumping, just do a spinal.
 
OP
excalibur

excalibur

Member
10+ Year Member
Oct 15, 2005
655
7
Status
Attending Physician
I put in FI blocks for almost all of my hip fractures, but the primary anesthetic is still GA or spinal. Occasionally I'll get a troch nail patient who gets GA + FI and has zero pain afterwards despite nothing more than ~50mcg fentanyl for the ETT or no narcotic (LMA), leading me to think that maybe I could get away with FI only for those cases. But even then setup time and reliability are big questions.

For anything more than a troch nail, even in the best case a FI block is almost certain to miss at least the posterior 1/3 of the acetabulum so I wouldn't have any hope of it being adequate as the sole anesthetic. A sciatic block is going to be too low, and if you're going to supplement with paravertebrals like Blade mentioned, what's the point of all the hoop-jumping, just do a spinal.
OK. Great this is what I was wondering. It seems that a troch nail could be done just under FICB...most likely.

Even with volume you are not likely going to have enough anesthetic to cover posterior hip for surgical anesthesia. And then if you are going to have to turn patient for some paravertebral block, you might as well just try for a spinal from the get go as mentioned.

FICB is still very handy though as it seems it could be enough surgical anesthesia for femoral nail, and excellent analgesia adjuvant when used together with GA for more invasive hip surgery
 

Oggg

ASA Member
May 2, 2011
962
21
Status
No wait. Just because you can do an IM nail with FICB+GA+zero narcs does not mean you can do it awake. That GA does a lot and you have to factor in the likely presence of morphine preop and postop. I believe that in a sick lil old pt, you can get by with minimal sedation and FICB but only because the minimal sedation knocks them out (ie ketamine 10mg is pretty heavy in an old demented pt, or even PPF 25m/k/m).

One thing I've started trying is this: do the FICB 12-15h before surgery. Usually this means doin the block in the evening before surgery. The FICB gives the pt pretty good pain relief so they can sleep well. I warn them that it will probably wear off before surgery, but at least you can sleep tonight - GA for the surgery and I tell them the pain is less after the hip is fixed. I only do this when I'm on call at the hosp and it's convenient for me. I always ask for local infiltration by the surgeon. I did this once for a small-incision surgeon for a hemi arthroplasty and it worked well (once).

The FICB only gets the lumbar plexus. It doesn't spread to the sacral plexus. A perfect LPB will not affect sciatic nerve function at all.
 

Oggg

ASA Member
May 2, 2011
962
21
Status
I have tried FICB +GA for hemiarthroplasty and total hip repl, and it seems to suck. Either the patient wakes up with 10/10 pain or I give morphine 10-15mg plus some more before they leave pacu. Right now I am saving it for pts who cannot get a SAB, and telling pts it's better than nothing
 
OP
excalibur

excalibur

Member
10+ Year Member
Oct 15, 2005
655
7
Status
Attending Physician
I have tried FICB +GA for hemiarthroplasty and total hip repl, and it seems to suck. Either the patient wakes up with 10/10 pain or I give morphine 10-15mg plus some more before they leave pacu. Right now I am saving it for pts who cannot get a SAB, and telling pts it's better than nothing
Have you tried FICB + GA for troch nail? Pgg has and states that it seems to work well. He states pts wake up with 0 pain. Maybe it's not enough for arthroplasties, but can work well for a few troch nails.
 

pgg

Laugh at me, will they?
Administrator
10+ Year Member
Dec 15, 2005
12,160
8,192
Home Again
Status
Attending Physician
Have you tried FICB + GA for troch nail? Pgg has and states that it seems to work well. He states pts wake up with 0 pain. Maybe it's not enough for arthroplasties, but can work well for a few troch nails.
0 pain isn't 100% of the time, and those FI/GA patients almost always get at least a little IV opiate anyway, so hard to know. I'm convinced it's effective and opiate sparing for most patients, which is why I do the block.

Despite that I wouldn't trust it for surgical anesthesia ... even if occasionally it seems to cover everything.


I like the idea of doing the FI block well in advance of the surgery though.
 
OP
excalibur

excalibur

Member
10+ Year Member
Oct 15, 2005
655
7
Status
Attending Physician
What concentration of local are you using, pgg? And how much volume?
 

pgg

Laugh at me, will they?
Administrator
10+ Year Member
Dec 15, 2005
12,160
8,192
Home Again
Status
Attending Physician
What concentration of local are you using, pgg? And how much volume?
Depends, about 40-50 mL depending on the size of the patient, and whether my drawer has two 30 mL syringes or if they only stocked 20s that day. To make the math easy I just start with 1/2 their body weight in kg = mL of 0.5% ropivacaine, then dilute to my desired volume. That way I get the high volume for the compartment block, but not more than 2.5 mg/kg of local.

I don't put any additives in though I've thought about adding dexamethasone.
 

Oggg

ASA Member
May 2, 2011
962
21
Status
Surgical stimulation is very intense during reduction and reaming and hammering, but they're covered up by the GA or SAB. Afterwards the bone hurts a lot less and the incisions have local in them, so postop pain is expected to be a lot less than the pain during surgery. I'd expect that you'd have to infuse heavy PPF during the procedure and basically do a room-air GA. You could try PPF boluses but then you risk pt movement which the surgeon will hate, and also apnea, agitation, aspiration, etc.
 

sevoflurane

Ride
15+ Year Member
Jul 16, 2003
4,951
1,773
Visit site
Status
Attending Physician
I've done hips with lumbar plexus + parasacral sciatics (best of all sciatic approaches for hips) + mag and ketafol infusions. Prep both blocks @ the same time and use the same needle to save time. I've had them work beautifully and have had to place an lma in a couple....

For nails... Especially with the elderly and the possibility of epidural spread with lumbar plexus blocks I do a simple GA @ 1/2 Mac with low dose fent/ketamine + USD guided fascia Illiaca block. If you are doing fascia illiacas w/o USD, your success rate is much lower. Especially with the biggens where it may be difficult to feel 2 distinct pops.