Fascia-Iliaca Compartment Block for Total Hip Arthroplasty?

[Oggg]

I asked today's orthopod if I could do a fascia-iliaca compartment block on the THA today, and I explained to him it would anesthetize the LFC, fem, and obturator nn. He said his incision is a large one and it goes posterolateral on the upper thigh, and he said the LFC covers the anteriorlateral upper thigh, so he was nervous about foregoing the intrathecal morphine. I didn't want to push for FICB + SAB + GETA, so we just went with the normal SAB +GETA.

Anyone have experience FICB and whether or not it misses some posterolateral thigh/hip? Anyone know what innervates posterolateral to the LFC? Do most people just do FICB (50cc 0.25%marcaine) +GA? Or FICB + SAB/morphine +/- GA?

I'm in private practice, and nobody here does nerve blocks. Most TKA/THA get SAB/GA or epid/GA. I'm trying to gently introduce various blocks (w/ultrasound), but of course I need the orthopods to buy into it.

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[ssmallz]

I asked today's orthopod if I could do a fascia-iliaca compartment block on the THA today, and I explained to him it would anesthetize the LFC, fem, and obturator nn. He said his incision is a large one and it goes posterolateral on the upper thigh, and he said the LFC covers the anteriorlateral upper thigh, so he was nervous about foregoing the intrathecal morphine. I didn't want to push for FICB + SAB + GETA, so we just went with the normal SAB +GETA.

Anyone have experience FICB and whether or not it misses some posterolateral thigh/hip? Anyone know what innervates posterolateral to the LFC? Do most people just do FICB (50cc 0.25%marcaine) +GA? Or FICB + SAB/morphine +/- GA?

I'm in private practice, and nobody here does nerve blocks. Most TKA/THA get SAB/GA or epid/GA. I'm trying to gently introduce various blocks (w/ultrasound), but of course I need the orthopods to buy into it.

Why start w/something so advanced? Start simple w/Fem-Sci's for TKAs, that should get good results for the orthopods and give youa good rep, then delve into more advanced blocks. My institution does a lot of regional but the Fascia Iliaca block is usually reserved for rescue situations. FWIW, hips are usually done w/a CSE and GA

 

[hivoltage]

with all these nerve blocks we are doing lately i can see some major major lawsuits coming down the pike...... foot drops, paresthesias, tingling hands, etc etc

 

[bogatyr]

I'm in private practice, and nobody here does nerve blocks. Most TKA/THA get SAB/GA or epid/GA. I'm trying to gently introduce various blocks (w/ultrasound), but of course I need the orthopods to buy into it.

Curious... why would you combine SAB + GA?

 

[Arch Guillotti]

I asked today's orthopod if I could do a fascia-iliaca compartment block on the THA today, and I explained to him it would anesthetize the LFC, fem, and obturator nn. He said his incision is a large one and it goes posterolateral on the upper thigh, and he said the LFC covers the anteriorlateral upper thigh, so he was nervous about foregoing the intrathecal morphine. I didn't want to push for FICB + SAB + GETA, so we just went with the normal SAB +GETA.

Anyone have experience FICB and whether or not it misses some posterolateral thigh/hip? Anyone know what innervates posterolateral to the LFC? Do most people just do FICB (50cc 0.25%marcaine) +GA? Or FICB + SAB/morphine +/- GA?

I'm in private practice, and nobody here does nerve blocks. Most TKA/THA get SAB/GA or epid/GA. I'm trying to gently introduce various blocks (w/ultrasound), but of course I need the orthopods to buy into it.

Why are you doing a general if you are also doing a spinal? Is your spinal narcotic only?

I agree with the above poster, keep it simple.

 

[IN2B8R]

Fascia iliaca block should be reserved for analgesia and not surgical anesthesia for total hip arthroplasty (i.e., when that 90 y.o. female is at the Emergency Department stage, getting medically cleared prior to coming to the OR...). Your standard SAB and IV sedation is what comes next when you are in the OR.... Cannot do a spinal? Then consider a lumbar plexus block: that will give you surgical anesthesia for total hips. If you cannot do that, then put the patient to sleep.... By the way, I have no idea whey you would do both GETA and SAB....

I asked today's orthopod if I could do a fascia-iliaca compartment block on the THA today, and I explained to him it would anesthetize the LFC, fem, and obturator nn. He said his incision is a large one and it goes posterolateral on the upper thigh, and he said the LFC covers the anteriorlateral upper thigh, so he was nervous about foregoing the intrathecal morphine. I didn't want to push for FICB + SAB + GETA, so we just went with the normal SAB +GETA.

Anyone have experience FICB and whether or not it misses some posterolateral thigh/hip? Anyone know what innervates posterolateral to the LFC? Do most people just do FICB (50cc 0.25%marcaine) +GA? Or FICB + SAB/morphine +/- GA?

I'm in private practice, and nobody here does nerve blocks. Most TKA/THA get SAB/GA or epid/GA. I'm trying to gently introduce various blocks (w/ultrasound), but of course I need the orthopods to buy into it.

 

[bostonblaz]

As I see it for a THA if you do a spinal with duramorph those people are sitting up eating breakfast with a smile the next day so i think it is a waste of time. I do like to do it for fractures in the holding area( if they are not too demented) and it a chance to set so when i roll them to do spinals i dont have to put them on the k-train and make them more crazy post op. I think it is the best to be used if you are doing a DHS. Block plus LMA does a great job an is opiod sparing post op. I also find it works well for IM rodding. Blaz

 

[Idiopathic]

Curious... why would you combine SAB + GA?

spares intraoperative opioid

 

[Idiopathic]

i dont know the data, but my personal anecdotal experience is that hips dont hurt anywhere near as bad as knees, and we have had enough complications with older patients and IT morphine that we really shy away from it anymore. Ill do a spinal for the case, but if the patient wants to go to sleep, then they go to sleep and get no IT or peripheral nerve block

 

[nap$ter]

spares intraoperative opioid

1. why do you need to give opioid to a pt c a sab?

2. if you do a GA + SAB, you'll likely have to give opioid anyhow.

GA+SAB makes no sense to me either...

 

[pgg]

Fascia iliaca block should be reserved for analgesia and not surgical anesthesia for total hip arthroplasty (i.e., when that 90 y.o. female is at the Emergency Department stage, getting medically cleared prior to coming to the OR...).

I do fascia iliaca blocks in almost all of my old people with hip fractures. Not much else though. Super fast, easy, and most of them get pretty good relief from it.

For the surgery, most of the time I put them to sleep. I'm not opposed to spinals for the fractures, but it just seems like 99% of the time they're anticoagulated, or demented, or non-English-speaking, or refuse the needle in the back ...



Never done a FI for a THA. Most get spinals with intrathecal morphine, the rest go to sleep. I think our orthopods would blow an aneurysm or coronary, or both, if we did anything freaky like a lumbar plexus block. Of course, these are the same guys who forbid femoral nerve blocks for their TKAs because whatever comic book journal they read had a case report of someone with quad weakness s/p FNB fall and break a hip on POD1. They can't be bargained with, they can't be reasoned with, they don't feel pity, or remorse, or fear for patients in pain. And they absolutely will not stop, ever ...

But I digress. Hips just don't seem to have anywhere near the postop pain knees do. I think intrathecal morphine is fine. It's easy fast and you get the surgical block done at the same time.

 

[pgg]

we have had enough complications with older patients and IT morphine that we really shy away from it anymore

What kind of complications, resp depression? What was the rest of their postop analgesic regimen and who was managing it? We had good results at my residency program, and at my current practice now. After intrathecal morphine we own their pain/sedation for 24 hours so we don't have problems with surgeons or other people giving them IV morphine, chased by a couple Percocets, chased by 50 mg of Benadryl for itching, chased by an Ambien to help them sleep, chased by [insert sedating med the ward nurse thinks the patient has to have at 2 AM].

1. why do you need to give opioid to a pt c a sab?

2. if you do a GA + SAB, you'll likely have to give opioid anyhow.

GA+SAB makes no sense to me either...

I offer IT morphine to most of my TAH patients before they go to sleep. They do well, especially the ones with 17 allergies, chronic pelvic pain, and a touch of the crazy that you just know are going to be a PITA in the PACU.

 

[imfrankie]

Curious... why would you combine SAB + GA?

Unfortunately one of the main reasons folks (at least used to) combine SAB with GA is payday. Put the IT morphine in with the SAB as the primary anesthetic is dollars A, put the IT morphine in then sleep the patient is dollars B.

Payday dictates a tremendous amount of what lots of anesthesiologists do, believe or not. ...I'm shocked!

 

[nap$ter]

I offer IT morphine to most of my TAH patients before they go to sleep. They do well, especially the ones with 17 allergies, chronic pelvic pain, and a touch of the crazy that you just know are going to be a PITA in the PACU.[/QUOTE]

if you're going to put morphine in the IT space, why not add local and forego the general? seems excessive to stick a needle in the back, and then sleep em.

an intraop propofol gtt is the best medicine for the potential PACU PITA...

 

[pgg]

if you're going to put morphine in the IT space, why not add local and forego the general? seems excessive to stick a needle in the back, and then sleep em.

The laparoscopy (which sometimes is a multi-hour ordeal) more or less obligates GETA. Some of our hysterectomies have a lot postop pain, usually the ones that were multi-hour ordeals. I'm no good at predicting the easy or hard ones, so I offer the IT narcs to almost all of them.

 

[12th man]

For old folk with broken femur, spinal duramorph 0.1 mg, and suggestion of propofol to keep them from pulling at the drapes. We do withhold duramorph is patient is less than vibrant.
For TAH, epidural and then GA/LMA.
Patients happy, surgeons happy.

 

[Outrigger]

FICB is a very basic block so I'm not sure why mention was made of femoral and sciatic being simpler blocks. FICB with a two pop technique is easier.

Our THA's are commonly done with an epidural and a propofol drip. You could bill it as GA with the epidural portion for postop pain relief.

A great alternate way is a CSE with the E portion being depodur not duramorph. This avoids issues with starting lovenox as in the above technique. Although to make it simple, just do a spinal and place duramorph. Epidural depodur will give you longer lasting pain relief than intrathecal duramorph.

Your most effective block would be the lumbar plexus but if there's a contraindication to doing an epidural or spinal, you'll have that same contraindication with the lumbar plexus.

 

[nap$ter]

The laparoscopy (which sometimes is a multi-hour ordeal) more or less obligates GETA. Some of our hysterectomies have a lot postop pain, usually the ones that were multi-hour ordeals. I'm no good at predicting the easy or hard ones, so I offer the IT narcs to almost all of them.

sneaky bas trd here we were talking about THA's, and you slipped in your recipe for TAH's... my HAT is off to you.

 

[sevoflurane]

FICB is a very basic block so I'm not sure why mention was made of femoral and sciatic being simpler blocks. FICB with a two pop technique is easier.

Absolutely. Easier than a femoral nerve block and 1/2 the time.

To answer one of your questions. Your orthopod doc was right as a FICB will not be very good for posteriorlateral part of the thigh. You'll get lucky from time to time... but not great. I don't know what approach he uses for his hips, but in general lateral fem. cutaneous can cover a good portion of the incision. As for effectiveness for THA....look at netter's osteotomes of the hip joint. You will get about 1/3 of the hip joint if amied upward under USD.

It's great for old ladies who have fallen and can't get up...🙂

http://www.ncbi.nlm.nih.gov/pubmed/17394987

 

[urge]

or non-English-speaking,

How does the pt's language affect your anesthetic?


Sounds like an oral board question.
😛

 

[sevoflurane]

We have a partner who does GA and SAB. Not my style, but when you are walking on POD #0, it works pretty well. Our data at our joint center suports this.

For THA, I'm either Lumbar Plexus (healthy..ish) vs. Fascia Iliaca (old and not so healthy..ish). I can knock those out pretty fast. The set up for a spinal would slow me down a little.

IMO, THA's def. hurt less than TKA's.

 

[urge]

A great alternate way is a CSE with the E portion being depodur not duramorph.

It is my understanding from talking to the pain guys that depodur has fallen out of favor due to respiratory depression.

Anyone heard of it?

 

[urge]

For THA, I'm either Lumbar Plexus (healthy..ish)

Are people really harpooning patients in pp? That needle scares the @#$^ out of me.

 

[sevoflurane]

Pent, Sux, tube... right? 😉

21G 4" neelde 95% of the time. I used to start with a 25g spinal needle to search out the TP... leave it and then follow it with the 21g (kinda like some people do with central lines and the finder needle.)

The one that scares me is the tuohy needle for LP catheter placement. That is a big daddy that can cause some havick. I haven't placed those in about 2 years.

Never biopsied the kidney, or aorta or even seen it poke out the front of the patient. It's the hypotension/epidural spread that has got me a couple of times early on.

They are really pretty simple and you might pass on poor protoplasm both from a medical perspective and BMI perspective.

It's the best analgesic for hips IMHO. Really nice when you get sacral roots as well. But it is not without risks. 🙄

 

[pgg]

How does the pt's language affect your anesthetic?

I've been burned by my inability to communicate with a patient during a non-supine regional anesthetic often enough that if there's no data or compelling reason to keep them awake, I lean toward putting them to sleep.

It's not that I'm insensitive to their cultural needs. 🙂

And I would not have said admitted the above during my oral board exam ... 😀

 

[Oggg]

1. Theoretically, the FICB is supposed to cover LFC, Fem, and Obturator, supposedly the same as Lumbar Plexus Block. Does the Lumbar Plexus block cover more than that? Superior gluteal nerve maybe? Sounds like I'll be saving the FICB for hip fractures, and my THAs will continue to get SAB/GA because I think I'm too scared to do lumbar plexus.

2. No one likes to be awake during joint surgery because they can hear and feel their body shake when the hammer comes down. You can bomb them with versed/fent and get PONV, or do a room air general (RAG) anesthestic with a PPF drip, in the lateral position. So a light general anesthetic makes a lot of sense, even if you don't take into account that it bills more too. Oh, and you can make the argument that it's a long surgery and the SAB might wear off, and my surgeons don't want epidurals because they want to start Lovenox bid.

 

[IN2B8R]

Sevo: I have pretty much adapted u/s guidance to all truncal blocks, including the lumbar plexus block.... Same with paravertebrals of all levels. Makes life safer, easier and more efficient--there's no going back. I pretty much do it same way as the guy in the below link. Gotta have the curvilinear probe for these deep blocks though...

http://youtu.be/sMyb7NRh5pE

Pent, Sux, tube... right? 😉

21G 4" neelde 95% of the time. I used to start with a 25g spinal needle to search out the TP... leave it and then follow it with the 21g (kinda like some people do with central lines and the finder needle.)

The one that scares me is the tuohy needle for LP catheter placement. That is a big daddy that can cause some havick. I haven't placed those in about 2 years.

Never biopsied the kidney, or aorta or even seen it poke out the front of the patient. It's the hypotension/epidural spread that has got me a couple of times early on.

They are really pretty simple and you might pass on poor protoplasm both from a medical perspective and BMI perspective.

It's the best analgesic for hips IMHO. Really nice when you get sacral roots as well. But it is not without risks. 🙄

 

[dbiddy808]

Are you guys serious? Or seriously naive? Units is the name of the game in private practice. Outcomes are hard to measure and most anesthesiologists weigh units vs effort and find their own personal balance.

For hip factures, your options are either GA + duramorph or GA + regional. Most patients are old and sick and duramorph has many potential complications. If you are doing regional and really want to make a difference you do a lumbar +/- sacral plexus block. Both of these are technically difficult to perform in a busy clinical practice, where you have 2-3 minutes to do your block. That leaves you with GA plus either the femoral 3 in 1 or the fascia iliaca. If we look at the available evidence they are equivalent. The fascia iliaca requires only landmarks and a blunt needle. It takes 30 seconds and gets you an additional 7 units for a femoral block.

Combine this with controlled hypotension and you have a good case. Sorry to be real about this, but for all the anesthesiologist I know, this is how they practice.....

 

[imfrankie]

Are you guys serious? Or seriously naive? Units is the name of the game in private practice. Outcomes are hard to measure and most anesthesiologists weigh units vs effort and find their own personal balance.

For hip factures, your options are either GA + duramorph or GA + regional. Most patients are old and sick and duramorph has many potential complications. If you are doing regional and really want to make a difference you do a lumbar +/- sacral plexus block. Both of these are technically difficult to perform in a busy clinical practice, where you have 2-3 minutes to do your block. That leaves you with GA plus either the femoral 3 in 1 or the fascia iliaca. If we look at the available evidence they are equivalent. The fascia iliaca requires only landmarks and a blunt needle. It takes 30 seconds and gets you an additional 7 units for a femoral block.

Combine this with controlled hypotension and you have a good case. Sorry to be real about this, but for all the anesthesiologist I know, this is how they practice.....

And of course many will bill for controlled hypotension, maybe put in an aline also. Running up the tab. Quarter at a time for medicare.

 

[IN2B8R]

Practice philosophies vary widely. Our surgeons request regional first, GA second when it comes to elderly, frail patients. We do care about the finances and units production, but patient concerns outweigh that in our practice.... Lumbar plexus blocks are not anymore time consuming than a spinal/epidural in our practice, again reflecting the different skill set and practice philisophies.... We have a good ancilliary staff that respects and supports the good health care that our group provides. I am in private practice and our turn over time is phenomenal.... You can look for all the "outcome" measures that you want, but clinical experience tells us that regional is better for the frail, older patients than GA. Just my two cents.

Are you guys serious? Or seriously naive? Units is the name of the game in private practice. Outcomes are hard to measure and most anesthesiologists weigh units vs effort and find their own personal balance.

For hip factures, your options are either GA + duramorph or GA + regional. Most patients are old and sick and duramorph has many potential complications. If you are doing regional and really want to make a difference you do a lumbar +/- sacral plexus block. Both of these are technically difficult to perform in a busy clinical practice, where you have 2-3 minutes to do your block. That leaves you with GA plus either the femoral 3 in 1 or the fascia iliaca. If we look at the available evidence they are equivalent. The fascia iliaca requires only landmarks and a blunt needle. It takes 30 seconds and gets you an additional 7 units for a femoral block.

Combine this with controlled hypotension and you have a good case. Sorry to be real about this, but for all the anesthesiologist I know, this is how they practice.....

 

[sevoflurane]

Sevo: I have pretty much adapted u/s guidance to all truncal blocks, including the lumbar plexus block.... Same with paravertebrals of all levels. Makes life safer, easier and more efficient--there's no going back. I pretty much do it same way as the guy in the below link. Gotta have the curvilinear probe for these deep blocks though...

http://youtu.be/sMyb7NRh5pE

Nice man... You gonna have to teach Dr. G-smith a thing or two next time you see him. 😀

Glad to see you are evolving. I can’t say I’ve done an LP under USD guidence.

That you tube vid was nice... you can actually see plexus nerves in that vid.

In your experience, do you find visualizing the plexus as easy as this vid? Admittedly, I still do blind LP, blind paravertebrals and ant. sciatics. Everything else is USDG. It may be time to buy a new probe for the USG LP.

You sell that big ***** house yet?

Take care bro. 🙂

 

[IN2B8R]

Nice man... You gonna have to teach Dr. G-smith a thing or two next time you see him. 😀

Glad to see you are evolving. I can't say I've done an LP under USD guidence.

That you tube vid was nice... you can actually see plexus nerves in that vid.

In your experience, do you find visualizing the plexus as easy as this vid? Admittedly, I still do blind LP, blind paravertebrals and ant. sciatics. Everything else is USDG. It may be time to buy a new probe for the USG LP.

You sell that big ***** house yet?

Take care bro. 🙂

With normal weight patients, you definitely see a nice psoas, often times with nerves there.... It is nice to use U/S because it makes things go faster and safer (IMO). House still on market....I'm thinking of selling it one brick at a time, since I might come out on top that way.... Anyhow, only about two hours away, so not the end of the world.... Curvilinear probe is very useful for other things also: can use it for TTE pre-op, quick scans for post-op patients, without need for sedation (an advantage over TEE). So, from that perspective, it sorta has dual uses and is definitely worth the investment....btw, I just came from the ASRA meeting in Vegas, was sort of disappointed I didn't run into anyone from our neck of the woods (but one of my partners and I made good use of our time..😉)

 

[sevoflurane]

Jensen was there... and was actually looking for someone to hook up with. You guys prolly just missed ea. other.

Tell you what... next time you head out to an ASRA conference, give me a ring and I'll promise to buy a brick or two off of your house.

Thanks for the info. 👍

 

[IN2B8R]

Jensen was there... and was actually looking for someone to hook up with. You guys prolly just missed ea. other.

Tell you what... next time you head out to an ASRA conference, give me a ring and I'll promise to buy a brick or two off of your house.

Thanks for the info. 👍

Hahaha, sounds good, bro' 😉

 

[Mman]

I think a Fascia Iliaca block provides nice analgesia for a hip. It isn't perfect, but it helps. It's also a very safe block that takes almost no time to perform. You get the LFCN and maybe a little femoral, but almost always will miss the obturator. But the obturator isn't innervating the hip, so doesn't really matter.

I confess to not doing it as often as I should, though. My usual technique is ultrasound guided and just drop 20 or 30 mls of local under the fascial plane. I usually do the block in the OR after induction and before intubation while the anesthetist is masking the patient. You don't need to do it awake because you aren't going anywhere near a nerve or even a blood vessel so there is no added safety with them being awake.

Helps decrease intraop and postop narcotics which is nice for your average elderly patient.