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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?
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?