Fascia Iliaca Block

[VentdependenT]

We routinely do this for post op knee pain s/p epidural removal at our private hospital.

Anyone have any experience with these? I'll supress my comments for now.

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[Ferdie]

why not just do a femoral nerve block?

 

[VentdependenT]

why not just do a femoral nerve block?

How would you do one on a post operative knee?

 

[usnavdoc]

How would you do one on a post operative knee?

With ultrasound. Not been impressed with fascia iliaca blocks. We have been doing continuous femoral catheters which can stay in longer than epidurals since the surgeons want to anticoagulate on POD2.

When we do use epidurals they come out the AM of POD2 and we simply transition them and sign off. The fem caths usually come out a bit later depending on d/c plans from ortho. To be honest though the time it generally takes to do a fem cath is a bit longer and more labor intensive than an epidural.

 

[Ferdie]

yeah, with U/S. We do them all the time (must have done 4 today. I'm the med student and I did 2 myself in the last 3 days. I'm kinda pumped because it's one of the coolest things I've done in med school, but also really, really easy). We also do fem catheters, but not as often - I saw one yesterday for a TKA. We usually leave those in overnight and pull the next day so that they can start active PT on POD 2. In my experience (which is not vast), the fem nerve catheters take hardly any more time than femoral blocks, which take much less time than epidurals.

 

[VentdependenT]

yeah, with U/S. We do them all the time (must have done 4 today. I'm the med student and I did 2 myself in the last 3 days. I'm kinda pumped because it's one of the coolest things I've done in med school, but also really, really easy). We also do fem catheters, but not as often - I saw one yesterday for a TKA. We usually leave those in overnight and pull the next day so that they can start active PT on POD 2. In my experience (which is not vast), the fem nerve catheters take hardly any more time than femoral blocks, which take much less time than epidurals.

Femoral catheters are a bitch to thread in. They move like crazy. I'm not impressed by them so far. When they work they are great.

Remember I'm talking post epidural on the floors. Not post-op in the PACU. Thats a 3 in 1 U/S with catheter always.

U/S guided FN block is the way to go. However, when I have 13 friggen blocks to do, I aint draggen that machine around, using 13 u/s condoms, and adding at least 3-5 min per block by having to hold the probe, push fluid while holding needle and probe to see needle tip, taping the PANUS up, and all the other nuances of nerve blockage by MYSELF. Hell no.

I now reserve the U/S for folks in which the fascia iliaca block doesn't work.

Does the fascia iliaca block work? Yup. Anecdotal 70-80% success rate. I love em damn it. They take me 20-30 seconds to perform from the time I put on my latex gloves. Keys are a b-bevel needle and slow advancement of needle to feel the "2 pops."

 

[Ferdie]

Does the fascia iliaca block work? Yup. Anecdotal 70-80% success rate. I love em damn it. They take me 20-30 seconds to perform from the time I put on my latex gloves. Keys are a b-bevel needle and slow advancement of needle to feel the "2 pops."

Cool, I'll have to see if we can try it here. Maybe I'll impress someone 😉

we do the fem blocks with u/s in the pacu and on the floor. a nice little trick to get around the u/s condom is by covering the probe with a giant tegaderm instead. You have to be careful for the cord then. I think we always have an attending around when blocks are being placed, so that makes these blocks a pretty easy thing to do as a 2-person process. If you're by yourself, yeah, that would be a big pain in the groin (we had this conversation just the other day at work, acutally)

 

[bubalus]

Femoral nerve block under US is probably the easiest and fastest one I do. I find the catheter is much easier to thread than any other block. You don't need a sterile sheath, but you should grab someone to hold he probe for you. Find your spot, prep, and put down an window drape, draping your prepped spot in and the probe out. I don't think I've ever had one not work. We get our knees up day of surgery with the block in. They just need an immobilizer, and they do CPM while in bed. Our patients LOVE it. Catheter out after 48 hours. That will virtually eliminate the risk of infection. We've had one skin pimple kind of infection in a catheter left in too long. That's out of >3000 femoral nerve catheters. If the surgeons will let you, you can even do a single shot 1/8% bupivacaine pop fossa block to get the sciatic distribution. That still leaves them a reasonable amount of motor but provides good analgesia.

 

[gasnewby]

one of our attendings puts a sterile glove over the u/s probe, instead of the condom. just watch the cord.

 

[Mman]

You mention that this is being done after epidurals are pulled postop on the floor. How long postop is the epidural usually left in place? We do a lot of LP/sciatic and fem/sciatic catheters for total knees that stay in until perhaps POD #2. If we use an epidural it depends on the surgeon how long they want it in, some are POD #1, some are POD #2.

But once whatever catheter they had in is pulled on the floor, it's generally time to be on PO pain meds (unless the catheter failed and they transition to PCA or what not).

 

[urge]

how do you do a "fascia iliaca block"?

 

[Ferdie]

how do you do a "fascia iliaca block"?

http://www.regionalabc.org/lower/block/fascia.php

this page seemed to have a good description. Sounds really easy.

 

[VentdependenT]

You mention that this is being done after epidurals are pulled postop on the floor. How long postop is the epidural usually left in place? We do a lot of LP/sciatic and fem/sciatic catheters for total knees that stay in until perhaps POD #2. If we use an epidural it depends on the surgeon how long they want it in, some are POD #1, some are POD #2.

But once whatever catheter they had in is pulled on the floor, it's generally time to be on PO pain meds (unless the catheter failed and they transition to PCA or what not).

POD #1. Not my idea.

 

[Noyac]

POD #1. Not my idea.

What are your surgeons using for DVT prophylaxis? Mine use lovenox. Don't want to be dealing with epidurals, when to pull them what to do if they are accidentally d/c'd, etc.

The fascia iliacus blocks are crap IMHO. And we have them doing PT on POD#1 so continuous blocks are out.

Our routine is intrathecal duramorph and a single shot FNB. I also add the single shot sciatic block thru the anterior approach just below the FNB site for posterior knee pain.

 

[VentdependenT]

What are your surgeons using for DVT prophylaxis? Mine use lovenox. Don't want to be dealing with epidurals, when to pull them what to do if they are accidentally d/c'd, etc.

The fascia iliacus blocks are crap IMHO. And we have them doing PT on POD#1 so continuous blocks are out.

Our routine is intrathecal duramorph and a single shot FNB. I also add the single shot sciatic block thru the anterior approach just below the FNB site for posterior knee pain.

They use lovenox or heparin bridge. PT does start on POD #1. I have found that folks can still do PT with epidural/FNCath.

Never done an anterior approach to the sciatic. In fact nobody at Rush does them that way. Sounds interesting however. SOme of these folks thighs are HUGE though. You gotta shove a 150mm in there?

 

[Noyac]

They use lovenox or heparin bridge. PT does start on POD #1. I have found that folks can still do PT with epidural/FNCath.

Never done an anterior approach to the sciatic. In fact nobody at Rush does them that way. Sounds interesting however. SOme of these folks thighs are HUGE though. You gotta shove a 150mm in there?

So you guys time the Lovenox and epidural D/C? Isn't that sort of a PITA?

And I agree that they can do PT with a cath in place but the CFNB cath is pretty limiting with the quads.

Why do some of you need the US for a FNB?

 

[usnavdoc]

So you guys time the Lovenox and epidural D/C? Isn't that sort of a PITA?

And I agree that they can do PT with a cath in place but the CFNB cath is pretty limiting with the quads.

Why do some of you need the US for a FNB?

We dont need the US for a FNB. He asked about post op knees. Which I assumed he did not want to use a stim.

Anyway, I just learned the anterior approach to sciatic. Pretty slick since you dont have to reposition and all.

 

[sevoflurane]

We dont need the US for a FNB. He asked about post op knees. Which I assumed he did not want to use a stim.

Anyway, I just learned the anterior approach to sciatic. Pretty slick since you dont have to reposition and all.

Yeah... but the anterior approach covers alot of real estate. If you are going to use USD... you can pick it off laterally. Safer IMHO.

 

[leaverus]

yeah, with U/S. We do them all the time (must have done 4 today. I'm the med student and I did 2 myself in the last 3 days. I'm kinda pumped because it's one of the coolest things I've done in med school, but also really, really easy). We also do fem catheters, but not as often - I saw one yesterday for a TKA. We usually leave those in overnight and pull the next day so that they can start active PT on POD 2. In my experience (which is not vast), the fem nerve catheters take hardly any more time than femoral blocks, which take much less time than epidurals.

Wow, your anesthesia dept. let's students do nerve blocks and epidurals? When i was a student i wasn't allowed to touch a patient having any of that kind of procedure being done.

 

[usnavdoc]

Yeah... but the anterior approach covers alot of real estate. If you are going to use USD... you can pick it off laterally. Safer IMHO.

I didnt mean we used the Us for Ant approach. We used a stim and landmarks.

 

[amyl]

Wow, your anesthesia dept. let's students do nerve blocks and epidurals? When i was a student i wasn't allowed to touch a patient having any of that kind of procedure being done.

i have done lateral sciatic blocks as a med student...haven't let me do anything else yet. had a bier block today but they let the crna do it 🙁
but i guess there is nothing to it...and i have done some on my horses anyway.

 

[Ferdie]

Wow, your anesthesia dept. let's students do nerve blocks and epidurals? When i was a student i wasn't allowed to touch a patient having any of that kind of procedure being done.

Med students don't do epidurals at my school. The rule is nothing that involves threading a catheter (for blocks, that is. foley catheters, unfortunately, we can thread all we want...). Spinals we are allowed to do, although I haven't had the chance. It depends on the attending's comfort level with it all, if the resident needs to get more proceedures under his/her belt, and if the patient will be easy. I tried an LP when I was on neuro, which is essentially a spinal, but it didn't go very well... (2 residents couldn't get it either though and she ended up in interventional radiology, so whatever)

 

[thegasman]

most people here (not a huge regional place) don't believe in fascia iliaca. Our tkas get us guided fem nerv cath - takes less than 5 minutes and very reliable. About half the time we do a single shot sciatic and then the patients get either a spinal or ga for the case (one surgeon is fast - his get sab, slow surgeon gets ga). They get bid lovenox on pod1 so epidurals are out. We do them for hips and pull them the next day though. The fem cath stays in untill pod2 to transition to po pain meds for discharge. It does not seem to get in the way of pt.

 

[amyl]

they are doing a study where i am rotating now with femoral with nerve stimulation vs. fascia iliaca. data's not in but preliminary ideas is that fascia iliaca is better when you get it ... femoral a little more reliable..

 

[epidural man]

most people here (not a huge regional place) don't believe in fascia iliaca. Our tkas get us guided fem nerv cath - takes less than 5 minutes and very reliable. About half the time we do a single shot sciatic and then the patients get either a spinal or ga for the case (one surgeon is fast - his get sab, slow surgeon gets ga). They get bid lovenox on pod1 so epidurals are out. We do them for hips and pull them the next day though. The fem cath stays in untill pod2 to transition to po pain meds for discharge. It does not seem to get in the way of pt.

FI blocks are great IMHO, but it is a field block that requires a large volume. If you don't use the volume, it won't work.

The truth is, if you have seen the femoral area under ultrasound and watched the tissues expand with local infiltration, it is hard not to believe in the FI because you see that local anywhere under that fascia will get the nerve. I agree with Venty, two pops in about two seconds. You can't beat that. No special equipment. B-bevel and local. I have used a tuohy several times for this also. This is a great needle to use because you can really feel the pops better. Often, the second pop is much less distinct. Maybe this is the reason for the failures, that the local was on top of the iliaca fascia.