Transcript The Fascia Iliaca Compartment Block

林必盛
中國醫藥大學
麻醉部
Indications
 The Fascia Iliaca Compartment Block (FICB) is a
simple block for post-operative pain relief for
procedures and injuries involving the hip, anterior
thigh, and knee. This block is useful, pre and postoperatively, for fractures of the hip and proximal femur,
as well as total hip and knee arthroplasties.
Anatomy of the Fascia Iliaca Block
Lateral
Femoral
Cutaneous
nerve
 The Lateral Femoral Cutaneous nerve is a purely
sensory nerve arising from the L2 & L3 nerve roots that
provides sensation from the iliac crest down the lateral
portion of the thigh to the area of the lateral femoral
condyle.
 The lateral femoral cutaneous nerve emerges from the
lumbar plexus and travels downward lateral to the
psoas muscle and crosses the iliacus muscle deep to
the iliacus fascia.
Obturator nerves
 The anterior and posterior Obturator nerves
innervate a portion of the distal, medial thigh. They
arise from the L2, L3, & L4 nerve roots and cross the
iliacus muscle, deep to the fascia, to the medial
thigh. The obturator nerves are sometimes involved in
the FICB but probably plays little role in post-operative
pain relief for most surgeries of the hip and proximal
femur.
Iliacus muscle
 The Iliacus muscle is a large, flat, triangular
muscle that lines and fills the ilium. It originates
from all along the upper portions of the ilium and
iliac crest, sacrum and iliolumbar ligaments. The
iliacus muscle joins with the lateral side of the
psoas major muscle. Together they are referred to
as the iliopsoas. The iliopsoas exits the pelvis from
beneath the inguinal ligament, wraps around the
proximal neck, and inserts into the lesser
trochanter, acting as a powerful hip flexor.
Fascia Iliaca
 The fascial covering of the iliopsoas is thin superiorly,
becoming significantly thicker as it reaches the level of
the inguinal ligament. This thickness provides a great
deal of resistance and a large “pop” as a needle tip is
passed through the fascia.
Lumbar plexus
 The lumbar plexus is made up of the nerve roots
from the T12 through L5 vertebrae. The largest
branch of the lumbar plexus is the Femoral nerve
is, arising from the L2, L3, & L4 roots. The femoral
nerve descends through the fibers of the psoas
major and exits at the lower portion of the psoas'
lateral border, passing downward between the
psoas and iliacus muscle, deep to the iliacus
fascia. The femoral nerve exits the pelvis into the
upper thigh, lateral to the common femoral artery
and vein.
Conventional Fascia Iliaca block
 This block use only surface landmarks and the feel of
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the needle as it passes the fascia lata and the iliacus
fascia (2 pops), to position the needle.
Introduce a needle just beneath that fascia.
Local anesthetic solution is then injected, creating a
local anesthetic filled space below the fascia.
As this local-filled space increases in size during
injection, the fluid travels cephalad beneath the fascia
and contacts the nerves of the lumbar plexus which
are located there.
These nerves are the lateral femoral cutaneous nerve,
the femoral nerve and the obturator nerves.
FICB block performed with the ultrasound
 Uses ultrasound to locate the superficial fascial layer of the
iliopsoas muscle at the anterior edge of the ilium.
 Ultrasound can assure that the needle tip is not only in the
correct plane, but to allow the operator to safely advance
the needle further into the fluid filled space after the initial
bolus of local anesthetic solution is concluded.
 Ultrasound also allow the operator to directly observe the
spread of the local solution cephalad, towards the superior
ilium during injection.
Practical points
 Since this is a compartment block, it needs use a fairly
large amount of volume to assure adequate spread of
the solution in the compartment, 40 to 50 mls being
commonly used.
 As a routine, use a total of 50 ml of local anesthetic
mixture injected incrementally, 10 – 15 ml after needle
placement.
 Advance the needle into the space created by the
volume, then inject the remainder of the local
anesthetic mix.
Alternate methods
 Some centers advocate injecting a bolus of normal
saline after the initial needle placement, to initiate
hydro-dissection of the sub-fascial plane, followed
by the local anesthetic solution.
 While this technique seems reasonable, since the
saline and the local will eventually occupy the
same space, it makes more sense to simply start
and end with the solution of the final
concentration.
Important notes
 Aspirate occasionally during injection of the local.
 When performing the fascia iliaca block you will
generally not see the local solution accumulating at
the site of injection. More commonly the local
solution will spread along the planes almost as soon
as it is injected.
 If you feel excessive resistance to injection, either
withdraw the needle slightly or advance it,
 Place manual pressure inferior to the injection site to
encourage antegrade flow towards the lumbar plexus.
CATHETER INSERTIONS
 If you are inserting a catheter into the fascia iliaca
compartment, do so after you have injected all of the
solutions. This will make sure there is ample space for
the catheter to move into as it is inserted.
 Too long a catheter may have a risk to migrate out of
the compartment.
 I.V. catheter may get kinked with the posture of the
patient and a stent inside the catheter can prevent
such condition.
Resident training
 3 residents: 1 R2 and 2 R3.
 Each has at least 3 hand on experiences.
 After which validation of correct placement was made
with ultrasound.
Result
Resident
R2
R3-1
R3-2
No. of hand on exp.
3
6
4
Successful block
2
6
4
2 good PCA
4 good PCA
3 good PCA
1 good PCA after
recannulation
1 excellent PCA
1 good post-op top
up
1 good post-op top
up
Validation
OK