Fascia Iliaca Block

CHECKLIST: nwh ed nerve block checklist

OVERVIEW: The infrainguinal fascia iliaca block is probably the best block for an ED patient with an acute hip fracture. It provides broader coverage than a femoral nerve block, and the motor sparing property of a PENG block is not necessary in a patient who will not be ambulatory before their surgery. The EMSL has recommended the Staten Island EM video lecture available here.

INDICATIONS: Best analgesia for acute hip fractures. Field block which affects lateral femoral cutaneous, femoral and obturator nerves providing analgesia to hip, femur, anterior and lateral thigh.

ANATOMY:  For this block, the large volume of anesthetic placed below the fascia iliaca spreads out to involve both the femoral nerve and the lateral femoral cutaneous nerve (and perhaps the obturator nerve). Scanning parallel to and below the inguinal crease, you should identify the NAVel mnemonic structures — femoral nerve, femoral artery, femoral vein.

Just lateral to the femoral artery and nerve is the iliopsoas muscle of which the iliacus is a part. The fascia iliaca runs superficial to the muscle. Our goal is to place anesthetic just below the fascia iliaca.

image from highlandultrasound.com

SUPPLIES:

  • In the NWH ED, you will need an ultrasound machine, a block tray, block needle and anesthetic (ropivacaine preferred), elsewhere the folllowing will be needed:
  • 20-40 mL Ropivacaine 0.5% (max 3 mg/kg of 5mg/mL) i.e. for 50kg use 30 mL, for 70kg use 42 mL.
  • 1% lidocaine for skin wheal
  • 25 gauge needle for local skin wheal
  • 5 cc syringe for skin wheal
  • Chlorhexidine skin prep
  • Large Curvilinear Transducer (greater insonation field than the other option – a linear transducer)
  • US gel packet
  • Saline flushes
  • 90 mm 22g Pajunk SonoMSK blunt-tip block needle
  • 91cm (or 36 inch) tubing

SAFETY:

  • Place on Monitor
  • Place on Pulse Oximetry
  • Ensure Intralipid is available to treat possible LAST (local anesthesia systemic toxicity)

PREPARATION:

  • Patient should be supine with bed flat
  • Machine on contralateral side to procedure
  • Survey Anatomy

PLACING THE BLOCK:

  • Prep with betadine or chlorhexidine
  • Place Skin wheal lateral to transducer
  • Advance needle just beyond fascia iliaca. You may feel two ‘pops’ as needle passes through the fascia lata and then fascia iliaca.
  • Hydrodissect using either normal saline or anesthetic and if your hydrodissection reveals the correct plane, deposit the remaining anesthetic.

ISSUES / TROUBLESHOOTING:

  • One common error is having your probe too low. If you see the femoral artery bifurcate, slide your probe cephalad to find the correct plane.
  • Another error is simply having your probe at an angle that is not parallel to the inguinal crease. This can make it difficult to see the NAVel structures well.