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Single Fascia Iliaca Compartment Block for Post-Hip Fracture Pain Relief
The Journal of Emergency Medicine, Vol. 32, No. 3, pp. 257–262, 2007 Copyright © 2007 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/07 $–see front matter
doi:10.1016/j.jemermed.2006.08.011
Original Contributions
SINGLE FASCIA ILIACA COMPARTMENT BLOCK FOR POST-HIP FRACTURE PAIN RELIEF Daniel Godoy Monzon,
MD,*
Kenneth V. Iserson,
MD, MBA, FACEP, FAAEM,†
and Jorge A. Vazquez,
MD‡
*Servicio de Ortopedia y Traumatologia, Instituto Carlos E. Ottolenghi, Hospital Italiano, Buenos Aires, Argentina, †Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona, and ‡Central de Emergencias, Hospital Italiano, Buenos Aires, Argentina Reprint Address: Kenneth V. Iserson, MD, Department of Emergency Medicine, University of Arizona College of Medicine, PO Box 24-5057, 1501 N. Campbell Avenue, Tucson, AZ 85724
procedure pain was reduced in all patients, but not completely abolished in any. Before the FICB, the pain ranged from 2 to 10 points (average 8.5) using the VAS; at 15 min post-injection, it ranged from 1 to 7 points (average 2.9); at 2 h post-injection, it ranged from 2 to 6 points (average 2.3); at 8 h post-injection, it ranged from 4 to 7 points (average 4.4). Analgesic requests in the first 24 h after admission averaged 1.2 doses (range 1 to 4 doses) of diclofenac 75 mg. There were no systemic complications and only two local hematomas. Resident physicians learned the procedure and could perform it successfully with less than 5 min instruction. Physicians rarely use the FICB in EDs, although the technique is simple to learn and use. This rapid, effective, and safe method of achieving excellent pain control in ED patients with hip fractures can be performed using standard ED equipment. © 2007 Elsevier Inc.
e Abstract—Hip fractures can cause considerable pain when untreated or under-treated. To enhance pain relief and diminish the risk of delirium from typically administered parenteral analgesics and continued pain, we tested the efficacy of using fascia-iliaca blocks (FICB), administered by one of four attending physicians working in the emergency department (ED), with commonly available ED equipment. After informed consent, a physician administered one FICB to 63 sequential adult ED patients (43 women, 20 men; ages 37–96 years, mean 73.5 years) with radiographically diagnosed hip fractures. Under aseptic conditions, a 21 g, 2-inch IM injection needle was inserted perpendicularly to the skin 1 cm below the juncture of the lateral and medial two-thirds of a line that joins the pubic tubercle to the anterior superior iliac spine. The needle was inserted until a loss of resistance was felt twice (fascia lata and fascia iliaca), at which point 0.3 mL/kg of 0.25 bupivacaine was infused. The physician tested the block’s efficacy by assessing sensory loss. Pain assessments were done using a 10-point Likert Visual Analog Scale (VAS) before, and at 15 min, 2 h, and 8 h post-block. Block failure was having the same level of pain as before the block. Oral analgesics were administered as needed. The IRB approved this study. Post-
e Keywords—regional anesthesia; hip fracture; analgesia; emergency medicine; geriatrics
INTRODUCTION More than 500,000 hip fractures occur annually in the United States (1). About 80% of the fall-related fractures occur in elderly women with osteoporosis (2,3). The mechanisms underlying hip fracture in the elderly are complex and multifactorial, involving an interaction between risks for falling and an age-associated decline in
Presented at the Society for Academic Emergency Medicine Annual Meeting (Poster presentation), New York, NY, May 25, 2005; First International Interdisciplinary Conference on Emergencies (IICE), Montreal, Canada, June 2005; First Inter-American Congress of Emergency Medicine, Buenos Aires, Argentina, April 20, 2006.
RECEIVED: 22 April 2005; FINAL ACCEPTED: 28 August 2006
SUBMISSION RECEIVED:
23 June 2006; 257
258
bone and muscle mass (possibly related to increased intake of animal proteins), and impairment of neuromuscular function (4,5). Hip fractures usually cause considerable pain. Untreated or under-treated pain and potent systemic analgesics can increase the risk of delirium, especially in elderly patients (6). The relationship of pain relief to decreased morbidity and mortality remains controversial (7,8). The benefits of the acute analgesia play an important role in patient comfort. It permits clinicians to take a more accurate history and do a better physical examination, improves systemic vital signs, and avoids the intense use of non-steroidal analgesics (with the accompanying risk of epigastric pain and coagulation abnormalities), or opioids (altering the sensorium). Therefore, the physician’s goal to relieve pain whenever possible in the most rapid and least damaging manner suggests that a safe and easily performed regional block, rather than mind-altering systemic analgesics, may be a very effective tool. Pain control is often not a high priority and systemic analgesics can cause or complicate problems, especially in the elderly population most susceptible to hip fractures. Elderly patients (50 years or older) with hip fractures report a 50% to 70% incidence of “severe to very severe” pain in the first 24 h post-injury (7). Although narcotics continue to be the mainstay for pre- and postoperative pain relief, in this patient group, avoiding or using very low doses of opioids to treat pain significantly decreases the risk to them of developing delirium (6). In this prospective study, we evaluated the feasibility, ease of use, and efficacy of using standard emergency department (ED) equipment to perform a single fascia
D. Godoy Monzon et al.
iliaca compartment block (FICB) for pain relief after a hip fracture.
MATERIALS AND METHODS This study was prospective, interventional, and uncontrolled. After informed consent, 63 sequential adult patients presenting to the ED and diagnosed with hip fracture radiographically were included in this study. Each received a single FICB from one of four attending physicians working in the ED. A standardized FICB technique was used for all patients (Figure 1). No premedication or sedation was used. The patient was placed in supine position, the inguinal ligament was identified and the femoral artery was palpated. The skin was cleaned with iodopovidone and the area was isolated using sterile drapes. A 21 g, 2-inch intramuscular injection needle (Terumo; Leuven, Belgium) was inserted perpendicular to the skin at a point 1 cm below the juncture of the lateral and medial twothirds of a line that joins the pubic tubercle to the anterior superior iliac spine. The needle was inserted until a loss of resistance was felt as the fascia lata was passed, and further advanced until a second loss of resistance occurred when the fascia iliaca was pierced (often described as two “pops”). With an attached syringe, we first performed aspiration to exclude intravascular injection, after which we injected approximately 0.3 mL/Kg of 0.25 bupivacaine. The block was never re-administered. The physician tested the block’s efficacy both subjectively and objectively by assessing sensory loss. Sensa-
Figure 1. Fascia iliaca block technique. A) The fascia iliaca compartment block. The needle is inserted perpendicular to the skin, 1 cm caudal to the inguinal ligament at the junction of the lateral one-third and the medial two-thirds of a line that joins the pubic spine (1) to the anterior superior iliac spine (2). B) Transverse view at the midinguinal ligament level. (3) Femoral vein; (4) femoral artery; (5) femoral nerve; (6) needle insertion for a femoral or three-in-one nerve block; (7) fascia lata; (8) fascia iliaca; (9) needle insertion for a fascia iliaca compartment block; (10) lateral femoral cutaneous nerve. (From: Atchabahian A, Brown AR. Anesthesiology 2001;94:534 – 6. Diagram “A,” “B,” with permission).
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Table 1. Patients’ Vital Signs, Including Pain (VAS) Evaluations Time post-block VAS (95% CI) p Value MAP HR RR
0
15 min
2 hours
8 hours
8.5 ⫾ 0.72 (6.89–9.71) – 133.3 ⫾ 15.1 148.5 ⫾ 15.7 23 ⫾ 4.1
2.9 ⫾ 0.16 (2.60–3.21) ⬍0.05 139.2 ⫾ 11.3 151.2 ⫾ 16.8 22.4 ⫾ 2.6
2.3 ⫾ 1.16 (1.56–4.79) ⬍0.05 110.2 ⫾ 10.8 82.4 ⫾ 10.3 20.8 ⫾ 3.2
4.4 ⫾ 0.91 (2.98–6.62) ⬍0.05 120.5 ⫾ 12.5 85.3 ⫾ 11.1 20.5 ⫾ 2.1
VAS ⫽ visual analog scale; MAP ⫽ mean arterial pressure; HR ⫽ heart rate; RR ⫽ respiratory rate.
tion was tested by palpating the skin over the affected hip. Subjective pain assessment was performed using a 10-point Likert Visual Analog Scale (VAS). This assessment was performed before block, at 15 min, 2 h, and 8 h after the block. Patients’ heart rate (HR), respiratory rate (RR), and mean arterial pressure (MAP) were assessed at the same intervals. Block failure was defined as the same level of pain and discomfort as before the block. Preoperatively, no patient was placed in traction. Postoperatively, an abduction pillow was used. No regular parenteral analgesia was prescribed, but oral analgesics, usually diclofenac 75 mg (Voltaren Delayed Release), were administered as needed. All patients had surgery within 48 h of admission. Other data collected included limited patient demographics, type of fracture, duration of analgesia, and the need for additional analgesics. Statistical analysis was performed for patients’ pain assessments corresponding to time zero (before application of the anesthetic block), and 15 min, 2 h, and 8 h after performing the block. Each group’s average and range of scores were determined, as was the standard deviation and the 95% confidence interval. The results using the VAS in the pre-block group were then compared for significance with those in the other groups using the Student’s t-test.
RESULTS Demographic Characteristics Sixty-three sequential patients were included in this study (43 women, 20 men), with ages ranging from 37 to 96 (mean 73.5) years. Thirty-nine had fractures on the right side and 24 on the left. Significant concomitant medical diseases included 9 patients with diabetes, 17 with hypertension, and 6 with both. One had a history of angina pectoris, 2 had undergone valve replacements, 5 had suffered contralateral hip fractures, and another had a laparotomy within the prior 2 months for colon cancer. These patients went on to have 25 total hip replacements, 21 dynamic hip screws, and 17 cephalic screws. Total hip replacement was performed in medial hip fracture with displacement (Garden grade 3 and 4). Screws were
used in cases with little or no displacement (Garden grade 1 and 2), and dynamic hip screws were used in lateral fractures (Evans classification). With dynamic hip screws, postoperative analgesia is very important, because rehabilitation is begun immediately.
Evaluation of the Block Significant differences (all with p ⬍ 0.05) were noted in the level of pain experienced by patients from 15 min to 8 h after the block (Table 1). The objective pain scores, also on a 1 to 10 scale, were almost identical to those of the VAS. The first post-block pain assessments were done 15 min after administration, so it is unclear how much faster the block may have begun decreasing pain in some patients. Because these patients with hip fractures did not ambulate before surgery, the only movement was when patients who had surgery within 8 h of block administration had their legs prepped and positioned for surgery. All of those patients allowed that positioning without significant pain or the need for additional analgesics. Although all study patients experienced pain relief postblock, some did not get as much relief as expected. During the 8-h observation period, there was a gradual trend toward normalization of vital signs and no change in their Glasgow Coma Scale scores. These patients’ analgesic requirements during the first 24 h after the entrance into the study averaged 1.2 doses (range 1 to 4) of 75 mg diclofenac. There were no systemic complications of the FICB and only two local hematomas at the injection site that resolved without additional interventions. Post-procedure, there was a subjective and objective reduction of pain in all patients, although it was not completely abolished in any patient.
DISCUSSION Dalens used the relatively recent anatomical description of the iliaca fascial compartment (IFC) to first describe the FICB procedure in 1989 (9,10). This closely fol-
260
lowed the publication of the procedure accidentally being done while trying to block the lateral femoral cutaneous nerve (11). Dalens described the procedure in contrast to the similar “3-in-1” block as being more successful (⬎90%), not requiring expensive equipment such as a neurostimulator, and being safer, because it was distant from the femoral neurovascular elements (9). Recent studies have found that the FICB is easier to perform, less costly, and has a more rapid onset than the 3-in-1 block (12). The widely used 3-in-1 block, first described by Winnie et al. in 1973, is designed to block, with one injection at the inguinal ligament, the femoral nerve, lateral cutaneous nerve of the thigh and the obturator nerve, all of which stem from the lumbar plexus. Success results from the proximal spread of local anesthetic injected around the femoral nerve to the other two nerves. Physicians generally use a nerve stimulator to locate the femoral nerve and to avoid some complications (13). Subsequently, the FICB primarily has been used, often as a continuous infusion through an indwelling catheter, for control of postoperative pain after hip, femoral shaft, thigh, patellar, and knee surgeries, both in adults and children. The FICB provides superior analgesia to that provided by the use of systemic morphine (14 –16). It also has been used in multi-trauma patients to decrease the need for systemic morphine and, barring other system reasons, reduce the time patients must remain intubated and artificially ventilated (17). It also has been successfully used bilaterally (18). Although prior studies have demonstrated the success of single-injection FICBs, they have rarely been used in Emergency Medicine and prehospital care (and then only on anesthesiologist-staffed ambulances) (19,20). Other blocks at the inguinal ligament have been used to treat hip fracture pain. The 3-in-1 block using a neurostimulator has also been occasionally used in EDs, especially in Europe (21). One ED study demonstrated the efficacy of ED use of 3-in-1 blocks without using a neural stimulator, although it required producing paresthesias to ascertain correct needle positioning (problematic in those elderly patients with diminished mental capacity), and it took 2.88 h post-block to reach the patient’s lowest pain score (22). Similarly, femoral nerve blocks have also been occasionally used for pain control in ED patients after hip fractures (23,24). Both of these blocks are performed near vital neurovascular structures. Although quickly gaining acceptance among anesthesiologists, the FICB has probably not yet been widely adopted in Emergency Medicine because it is relatively new and has been described only in the anesthesia literature. The more complicated 3-in-1 block did not appear in the Emergency Medicine literature until 1988, 15 years after it was first described; it only found
D. Godoy Monzon et al.
its way into the U.S. Emergency Medicine literature in 2003 (22,24). Anatomically, the FICB is an anterior regional anesthetic block of the lumbar plexus, specifically the femoral, lateral femoral cutaneous (LFC), and obturator nerves. Although the block is done below the level of a hip fracture, anatomical studies on adult cadavers and living patients demonstrate that anesthetic solution injected into the fascia iliaca compartment spreads to the nerves innervating the hip, and may reach the femoral and lateral cutaneous nerve of the thigh and then spread medially over the psoas muscle. The deep fascial fold between the psoas and iliacus muscles may act as a barrier to the anesthetic reaching the obturator nerve in some patients (25). The anesthetic rarely reaches the lumbar plexus (26). The action of the FICB is similar to the commonly used 3-in-1 block, although the FICB has been shown to be much simpler to perform, have a more rapid onset, and be more effective, at least in adults, for simultaneously blocking the lateral femoral cutaneous nerve of the thigh, and femoral nerves (26). The 3-in-1 block often fails because the catheter is not placed under the fascia iliaca, and the success rate does not improve with either the use of a neurostimulator or increased doses of local anesthetic (26,27). After these failures or failures to perform standard lumbar plexus blocks, the FICB has been easily used. It has also been used as a route for continuous infusion of local anesthetic after knee surgery (although the authors called it a type of 3-in-1 block) (28,29). Only 35% of patients get complete sensory blockade to the three lumbar nerves supplying the thigh from either the FICB or the 3-in-1 blocks. Complete block primarily depends upon whether the obturator nerve is blocked—which may be difficult to obtain and unpredictable (30). The difficulty is that, although injected anesthetic entering the IFC blocks the femoral and LFC nerves, sufficient anesthetic does not always migrate proximally to block the obturator nerve, which, with the genitofemoral nerve, lies on the internal edge of the psoas muscle in a separate plane from the femoral and LFC nerves (31). With the FICB, an early predictor of optimal pain relief for femur fractures is a sensory block of the inner thigh (19). We report two minor complications (local hematomas) of the procedure. There has been only one prior report of a complication after an FICB. Because the injection site is distant from the femoral nerve and vessels, it is much safer than the 3-in-1 block. Reporting one case of a persistent sensory deficit after a post-operative (total hip replacement) FICB when the patient was not in a condition to report paresthesias during the procedure (which should not, in any event, be necessary), the au-
Fascia Iliaca Block
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thors suggested that the sensory deficit may have been due to her surgery, incorrect placement of the needle, or a normal anatomic variant. The problem resolved after 8 days (32). FICB has rarely been used in Emergency Medicine, although the technique is remarkably simple to learn and use. One study demonstrated its effectiveness in prehospital care, although an anesthesiologist who typically staffed ambulances in that system administered the FICB. In our study, the single-injection FICB produced significant benefit by controlling pain far better than standard parenteral medications without any evidence of increased delirium. We also found that it allowed us to obtain a better history from and physical examination of the patient, including more normal vital signs. Analgesic requirements after FICB injection were minimal, far less than normally used, and limited to non-parenteral antiinflammatory agents. The apparent prolonged analgesic effect (8 h) was unexpected, but possibly due to the large fascial space with substantial surrounding muscle mass into which it was injected. The limitation of this study were that, although marked pain diminishment was demonstrated preoperatively, after epidural anesthesia (with sedation) used for many of these patients’ surgeries, they lacked pain sensation for a prolonged period. After awakening from general anesthesia, they experienced some discomfort. These situations, however, are standard practice, and patient outcomes should be similar wherever they are used.
3.
4. 5.
6.
7.
8. 9.
10.
11. 12.
13.
14.
15.
CONCLUSIONS 16.
The FICB is a rapid, effective, safe and easily performed method of achieving excellent pain control in ED patients with hip fractures. Emergency physicians can perform the FICB with standard ED equipment and the procedure is easy to learn. Based on extensive literature that demonstrates its utility, future studies will explore the efficacy of using the FICB for knee and femoral shaft fractures in adults and children. A particular group that might benefit from FICB use is multiple trauma patients with hip, femoral shaft, and knee injuries who would need less systemic and potentially destabilizing analgesics using the FICB.
17.
18.
19.
20.
21.
REFERENCES 22. 1. Centers for Disease Control and Prevention. Falls and hip fractures among older adults. Available at: www.cdc.gov/ncipc/factsheets/ falls.htm. Accessed September 13, 2004. 2. Ray NF, Chan JK, Thamer M, Melton LJ III. Medical expenditures for the treatment of osteoporotic fractures in the United States in
23.
1995: report from the National Osteoporosis foundation. J Bone Miner Res 1997;12:24 –35. Stevens JA, Olson S. Reducing falls and resulting hip fractures among older women. CDC recommendations regarding selected conditions affecting women’s health. MMWR Recomm Rep 2000; 49:3–12. Fisher A, Davis M, Budge M. Broader strategies for hip fracture prevention. Am J Med 2004;117:137– 8. Frassetto LA, Todd KM, Morris RC Jr, Sabastian A. Worldwide incidence of hip fracture in elderly women: relation to consumption of animal and vegetable foods. J Gerontol A Biol Sci Med Sci 2000;55:M585–92. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003;58:76 – 81. Orosz GM, Magaziner J, Hannan EL, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA 2004;291: 1738 – 43. Bonica JJ. Improtance of effective pain control. Acta Anaeshesiol Scand 1987;31(Suppl 85):1–16. Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca block with the 3-in-1 block in children. Anesth Analg 1989; 69:705–13. Khoo ST, Brown TCK. Femoral nerve block: the anatomical basis for a single injection technique. Anaesth Intensive Care 1983;11: 40 –2. Sharrock NE. Inadvertent “3-in-1” block following injection of the lateral cutaneous nerve of the thigh. Anesth Analg 1989;59:887– 8. Morau D, Lopez S, Biboulet P, Bernard N, Amar J, Capdevila X. Comparison of continuous 3-in-1 and fascia iliaca compartment blocks for postoperative analgesia: feasibility, catheter migration, distribution of sensory block, and analgesic efficacy. Reg Anesth Pain Med 2003;28:309 –14. Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technic of lumbar plexus anaesthesia. The “3-in-1 Block.” Anesth Analg 1973;52:989 –96. Matheny JM, Hanks GA, Rung GW, et al. Comparison of patientcontrolled analgesia and continuous lumbar plexus block after anterior cruciate ligament reconstruction. Arthroscopy 1993;9: 87–90. Serpell MG, Millar FA, Thomson MF. Comparison of lumbar plexus block versus conventional opiod analgesia after total knee replacement. Anaesthesia 1991;46:275–7. Cuignet O, Pirson J, Boughrouph J, Duville D. The efficacy of continuous fascia iliaca compartment block for pain management in burn patients undergoing skin grafting procedures. Anesth Analg 2004;98:1077– 81. Barthelet Y, Morau D, Roustan JP, Parer S. Evaluation of the interest of regional analgesia by femoral catheter in a traumatologic intensive care unit (abstract). Available at: www.iars.org/ abstracts/abstracts/S497/S499.htm. Accessed September 7, 2004. Longo SR, Williams DP. Bilateral fascia iliaca catheters for postoperative pain control after bilateral total knee arthroplasty: a case report and description of a catheter technique. Reg Anesth 1997; 22:372–7. Lopez S, Gros T, Bernard N, Plasse C, Capdevila X. Fascia iliaca compartment block for femoral bone fractures in prehospital care. Reg Anesth Pain Med 2003;28:203–7. Gros T, Hatterer E, Plasse C, de la Coussaye JE. Bloc iliofascial en médecine préhospitalière. Annales françaises danesthèsie et de rèanimation. 1999;18:282–3. Van Leeuwen FL, Bronselaer K, Gilles M, et al. The “three in one” block as locoregional analgesia in the emergency department. Eur J Emerg Med 2000;7:35– 8. Fletcher AK, Rigby AS, Heyes FLP. Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med 2003; 41:227–33. Haddad FS, Williams RL. Femoral nerve block in extracapsular femoral neck fractures. J Bone Joint Surg 1995;77:922–3.
262 24. Finlayson BJ, Underhill TJ. Femoral nerve block for analgesia in fractures of the femoral neck. Arch Emerg Med 1988;5:173– 6. 25. Foulds JS, Peutrell JM, Shaw-Dunn J. The anatomy of the fascia iliaca compartment block. Clin Anat 2002;15(1):73 (abstract). 26. Capdevila X, Biboulet P, Bouregba M, Barthelet Y, Rubenovitch J, d’Athis F. Comparison of the three-in-one and fascia iliaca compartment blocks in adults: clinical and radiolographic analysis. Anesth Analg 1998;86:1039 – 44. 27. Seeberger MD, Urwyler A. Paravascular lumbar plexus block extension after femoral nerve stimulation and injection of 20 vs 40 ml mepivacaine 10 mg/ml. Acta Anaesthesiol Scand 1995;39:769 –73.
D. Godoy Monzon et al. 28. Aveline C, Bonnet F. Delayed retroperitoneal haematoma after failed lumbar plexus block. Br J Anaesthesia 2004;93:589 –91. 29. Ganapathy S, Wasserman RA, Watson JT, et al. Modified continuous femoral three-in-one block for postoperative pain after total knee arthroplasty. Anesth Analg 1999;89:1197–202. 30. Cauhepe C, Olivier M, Columbani R, et al. The “3 in1” block: myth or reality? Ann Fr Anesth Reanim 1989;8:376 – 8. 31. Farny J, Drolet P, Girard M. Anatomy of the posterior approach to the lumbar plexus block. Can J Anaesth 1994;41:480 –5. 32. Arthur A, Brown AR. Postoperative neuropathy following fascia iliaca compartment blockade. Anesthesiology 2001;94:534 – 6.
doi:10.1016/j.jemermed.2006.08.011
Original Contributions
SINGLE FASCIA ILIACA COMPARTMENT BLOCK FOR POST-HIP FRACTURE PAIN RELIEF Daniel Godoy Monzon,
MD,*
Kenneth V. Iserson,
MD, MBA, FACEP, FAAEM,†
and Jorge A. Vazquez,
MD‡
*Servicio de Ortopedia y Traumatologia, Instituto Carlos E. Ottolenghi, Hospital Italiano, Buenos Aires, Argentina, †Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona, and ‡Central de Emergencias, Hospital Italiano, Buenos Aires, Argentina Reprint Address: Kenneth V. Iserson, MD, Department of Emergency Medicine, University of Arizona College of Medicine, PO Box 24-5057, 1501 N. Campbell Avenue, Tucson, AZ 85724
procedure pain was reduced in all patients, but not completely abolished in any. Before the FICB, the pain ranged from 2 to 10 points (average 8.5) using the VAS; at 15 min post-injection, it ranged from 1 to 7 points (average 2.9); at 2 h post-injection, it ranged from 2 to 6 points (average 2.3); at 8 h post-injection, it ranged from 4 to 7 points (average 4.4). Analgesic requests in the first 24 h after admission averaged 1.2 doses (range 1 to 4 doses) of diclofenac 75 mg. There were no systemic complications and only two local hematomas. Resident physicians learned the procedure and could perform it successfully with less than 5 min instruction. Physicians rarely use the FICB in EDs, although the technique is simple to learn and use. This rapid, effective, and safe method of achieving excellent pain control in ED patients with hip fractures can be performed using standard ED equipment. © 2007 Elsevier Inc.
e Abstract—Hip fractures can cause considerable pain when untreated or under-treated. To enhance pain relief and diminish the risk of delirium from typically administered parenteral analgesics and continued pain, we tested the efficacy of using fascia-iliaca blocks (FICB), administered by one of four attending physicians working in the emergency department (ED), with commonly available ED equipment. After informed consent, a physician administered one FICB to 63 sequential adult ED patients (43 women, 20 men; ages 37–96 years, mean 73.5 years) with radiographically diagnosed hip fractures. Under aseptic conditions, a 21 g, 2-inch IM injection needle was inserted perpendicularly to the skin 1 cm below the juncture of the lateral and medial two-thirds of a line that joins the pubic tubercle to the anterior superior iliac spine. The needle was inserted until a loss of resistance was felt twice (fascia lata and fascia iliaca), at which point 0.3 mL/kg of 0.25 bupivacaine was infused. The physician tested the block’s efficacy by assessing sensory loss. Pain assessments were done using a 10-point Likert Visual Analog Scale (VAS) before, and at 15 min, 2 h, and 8 h post-block. Block failure was having the same level of pain as before the block. Oral analgesics were administered as needed. The IRB approved this study. Post-
e Keywords—regional anesthesia; hip fracture; analgesia; emergency medicine; geriatrics
INTRODUCTION More than 500,000 hip fractures occur annually in the United States (1). About 80% of the fall-related fractures occur in elderly women with osteoporosis (2,3). The mechanisms underlying hip fracture in the elderly are complex and multifactorial, involving an interaction between risks for falling and an age-associated decline in
Presented at the Society for Academic Emergency Medicine Annual Meeting (Poster presentation), New York, NY, May 25, 2005; First International Interdisciplinary Conference on Emergencies (IICE), Montreal, Canada, June 2005; First Inter-American Congress of Emergency Medicine, Buenos Aires, Argentina, April 20, 2006.
RECEIVED: 22 April 2005; FINAL ACCEPTED: 28 August 2006
SUBMISSION RECEIVED:
23 June 2006; 257
258
bone and muscle mass (possibly related to increased intake of animal proteins), and impairment of neuromuscular function (4,5). Hip fractures usually cause considerable pain. Untreated or under-treated pain and potent systemic analgesics can increase the risk of delirium, especially in elderly patients (6). The relationship of pain relief to decreased morbidity and mortality remains controversial (7,8). The benefits of the acute analgesia play an important role in patient comfort. It permits clinicians to take a more accurate history and do a better physical examination, improves systemic vital signs, and avoids the intense use of non-steroidal analgesics (with the accompanying risk of epigastric pain and coagulation abnormalities), or opioids (altering the sensorium). Therefore, the physician’s goal to relieve pain whenever possible in the most rapid and least damaging manner suggests that a safe and easily performed regional block, rather than mind-altering systemic analgesics, may be a very effective tool. Pain control is often not a high priority and systemic analgesics can cause or complicate problems, especially in the elderly population most susceptible to hip fractures. Elderly patients (50 years or older) with hip fractures report a 50% to 70% incidence of “severe to very severe” pain in the first 24 h post-injury (7). Although narcotics continue to be the mainstay for pre- and postoperative pain relief, in this patient group, avoiding or using very low doses of opioids to treat pain significantly decreases the risk to them of developing delirium (6). In this prospective study, we evaluated the feasibility, ease of use, and efficacy of using standard emergency department (ED) equipment to perform a single fascia
D. Godoy Monzon et al.
iliaca compartment block (FICB) for pain relief after a hip fracture.
MATERIALS AND METHODS This study was prospective, interventional, and uncontrolled. After informed consent, 63 sequential adult patients presenting to the ED and diagnosed with hip fracture radiographically were included in this study. Each received a single FICB from one of four attending physicians working in the ED. A standardized FICB technique was used for all patients (Figure 1). No premedication or sedation was used. The patient was placed in supine position, the inguinal ligament was identified and the femoral artery was palpated. The skin was cleaned with iodopovidone and the area was isolated using sterile drapes. A 21 g, 2-inch intramuscular injection needle (Terumo; Leuven, Belgium) was inserted perpendicular to the skin at a point 1 cm below the juncture of the lateral and medial twothirds of a line that joins the pubic tubercle to the anterior superior iliac spine. The needle was inserted until a loss of resistance was felt as the fascia lata was passed, and further advanced until a second loss of resistance occurred when the fascia iliaca was pierced (often described as two “pops”). With an attached syringe, we first performed aspiration to exclude intravascular injection, after which we injected approximately 0.3 mL/Kg of 0.25 bupivacaine. The block was never re-administered. The physician tested the block’s efficacy both subjectively and objectively by assessing sensory loss. Sensa-
Figure 1. Fascia iliaca block technique. A) The fascia iliaca compartment block. The needle is inserted perpendicular to the skin, 1 cm caudal to the inguinal ligament at the junction of the lateral one-third and the medial two-thirds of a line that joins the pubic spine (1) to the anterior superior iliac spine (2). B) Transverse view at the midinguinal ligament level. (3) Femoral vein; (4) femoral artery; (5) femoral nerve; (6) needle insertion for a femoral or three-in-one nerve block; (7) fascia lata; (8) fascia iliaca; (9) needle insertion for a fascia iliaca compartment block; (10) lateral femoral cutaneous nerve. (From: Atchabahian A, Brown AR. Anesthesiology 2001;94:534 – 6. Diagram “A,” “B,” with permission).
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Table 1. Patients’ Vital Signs, Including Pain (VAS) Evaluations Time post-block VAS (95% CI) p Value MAP HR RR
0
15 min
2 hours
8 hours
8.5 ⫾ 0.72 (6.89–9.71) – 133.3 ⫾ 15.1 148.5 ⫾ 15.7 23 ⫾ 4.1
2.9 ⫾ 0.16 (2.60–3.21) ⬍0.05 139.2 ⫾ 11.3 151.2 ⫾ 16.8 22.4 ⫾ 2.6
2.3 ⫾ 1.16 (1.56–4.79) ⬍0.05 110.2 ⫾ 10.8 82.4 ⫾ 10.3 20.8 ⫾ 3.2
4.4 ⫾ 0.91 (2.98–6.62) ⬍0.05 120.5 ⫾ 12.5 85.3 ⫾ 11.1 20.5 ⫾ 2.1
VAS ⫽ visual analog scale; MAP ⫽ mean arterial pressure; HR ⫽ heart rate; RR ⫽ respiratory rate.
tion was tested by palpating the skin over the affected hip. Subjective pain assessment was performed using a 10-point Likert Visual Analog Scale (VAS). This assessment was performed before block, at 15 min, 2 h, and 8 h after the block. Patients’ heart rate (HR), respiratory rate (RR), and mean arterial pressure (MAP) were assessed at the same intervals. Block failure was defined as the same level of pain and discomfort as before the block. Preoperatively, no patient was placed in traction. Postoperatively, an abduction pillow was used. No regular parenteral analgesia was prescribed, but oral analgesics, usually diclofenac 75 mg (Voltaren Delayed Release), were administered as needed. All patients had surgery within 48 h of admission. Other data collected included limited patient demographics, type of fracture, duration of analgesia, and the need for additional analgesics. Statistical analysis was performed for patients’ pain assessments corresponding to time zero (before application of the anesthetic block), and 15 min, 2 h, and 8 h after performing the block. Each group’s average and range of scores were determined, as was the standard deviation and the 95% confidence interval. The results using the VAS in the pre-block group were then compared for significance with those in the other groups using the Student’s t-test.
RESULTS Demographic Characteristics Sixty-three sequential patients were included in this study (43 women, 20 men), with ages ranging from 37 to 96 (mean 73.5) years. Thirty-nine had fractures on the right side and 24 on the left. Significant concomitant medical diseases included 9 patients with diabetes, 17 with hypertension, and 6 with both. One had a history of angina pectoris, 2 had undergone valve replacements, 5 had suffered contralateral hip fractures, and another had a laparotomy within the prior 2 months for colon cancer. These patients went on to have 25 total hip replacements, 21 dynamic hip screws, and 17 cephalic screws. Total hip replacement was performed in medial hip fracture with displacement (Garden grade 3 and 4). Screws were
used in cases with little or no displacement (Garden grade 1 and 2), and dynamic hip screws were used in lateral fractures (Evans classification). With dynamic hip screws, postoperative analgesia is very important, because rehabilitation is begun immediately.
Evaluation of the Block Significant differences (all with p ⬍ 0.05) were noted in the level of pain experienced by patients from 15 min to 8 h after the block (Table 1). The objective pain scores, also on a 1 to 10 scale, were almost identical to those of the VAS. The first post-block pain assessments were done 15 min after administration, so it is unclear how much faster the block may have begun decreasing pain in some patients. Because these patients with hip fractures did not ambulate before surgery, the only movement was when patients who had surgery within 8 h of block administration had their legs prepped and positioned for surgery. All of those patients allowed that positioning without significant pain or the need for additional analgesics. Although all study patients experienced pain relief postblock, some did not get as much relief as expected. During the 8-h observation period, there was a gradual trend toward normalization of vital signs and no change in their Glasgow Coma Scale scores. These patients’ analgesic requirements during the first 24 h after the entrance into the study averaged 1.2 doses (range 1 to 4) of 75 mg diclofenac. There were no systemic complications of the FICB and only two local hematomas at the injection site that resolved without additional interventions. Post-procedure, there was a subjective and objective reduction of pain in all patients, although it was not completely abolished in any patient.
DISCUSSION Dalens used the relatively recent anatomical description of the iliaca fascial compartment (IFC) to first describe the FICB procedure in 1989 (9,10). This closely fol-
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lowed the publication of the procedure accidentally being done while trying to block the lateral femoral cutaneous nerve (11). Dalens described the procedure in contrast to the similar “3-in-1” block as being more successful (⬎90%), not requiring expensive equipment such as a neurostimulator, and being safer, because it was distant from the femoral neurovascular elements (9). Recent studies have found that the FICB is easier to perform, less costly, and has a more rapid onset than the 3-in-1 block (12). The widely used 3-in-1 block, first described by Winnie et al. in 1973, is designed to block, with one injection at the inguinal ligament, the femoral nerve, lateral cutaneous nerve of the thigh and the obturator nerve, all of which stem from the lumbar plexus. Success results from the proximal spread of local anesthetic injected around the femoral nerve to the other two nerves. Physicians generally use a nerve stimulator to locate the femoral nerve and to avoid some complications (13). Subsequently, the FICB primarily has been used, often as a continuous infusion through an indwelling catheter, for control of postoperative pain after hip, femoral shaft, thigh, patellar, and knee surgeries, both in adults and children. The FICB provides superior analgesia to that provided by the use of systemic morphine (14 –16). It also has been used in multi-trauma patients to decrease the need for systemic morphine and, barring other system reasons, reduce the time patients must remain intubated and artificially ventilated (17). It also has been successfully used bilaterally (18). Although prior studies have demonstrated the success of single-injection FICBs, they have rarely been used in Emergency Medicine and prehospital care (and then only on anesthesiologist-staffed ambulances) (19,20). Other blocks at the inguinal ligament have been used to treat hip fracture pain. The 3-in-1 block using a neurostimulator has also been occasionally used in EDs, especially in Europe (21). One ED study demonstrated the efficacy of ED use of 3-in-1 blocks without using a neural stimulator, although it required producing paresthesias to ascertain correct needle positioning (problematic in those elderly patients with diminished mental capacity), and it took 2.88 h post-block to reach the patient’s lowest pain score (22). Similarly, femoral nerve blocks have also been occasionally used for pain control in ED patients after hip fractures (23,24). Both of these blocks are performed near vital neurovascular structures. Although quickly gaining acceptance among anesthesiologists, the FICB has probably not yet been widely adopted in Emergency Medicine because it is relatively new and has been described only in the anesthesia literature. The more complicated 3-in-1 block did not appear in the Emergency Medicine literature until 1988, 15 years after it was first described; it only found
D. Godoy Monzon et al.
its way into the U.S. Emergency Medicine literature in 2003 (22,24). Anatomically, the FICB is an anterior regional anesthetic block of the lumbar plexus, specifically the femoral, lateral femoral cutaneous (LFC), and obturator nerves. Although the block is done below the level of a hip fracture, anatomical studies on adult cadavers and living patients demonstrate that anesthetic solution injected into the fascia iliaca compartment spreads to the nerves innervating the hip, and may reach the femoral and lateral cutaneous nerve of the thigh and then spread medially over the psoas muscle. The deep fascial fold between the psoas and iliacus muscles may act as a barrier to the anesthetic reaching the obturator nerve in some patients (25). The anesthetic rarely reaches the lumbar plexus (26). The action of the FICB is similar to the commonly used 3-in-1 block, although the FICB has been shown to be much simpler to perform, have a more rapid onset, and be more effective, at least in adults, for simultaneously blocking the lateral femoral cutaneous nerve of the thigh, and femoral nerves (26). The 3-in-1 block often fails because the catheter is not placed under the fascia iliaca, and the success rate does not improve with either the use of a neurostimulator or increased doses of local anesthetic (26,27). After these failures or failures to perform standard lumbar plexus blocks, the FICB has been easily used. It has also been used as a route for continuous infusion of local anesthetic after knee surgery (although the authors called it a type of 3-in-1 block) (28,29). Only 35% of patients get complete sensory blockade to the three lumbar nerves supplying the thigh from either the FICB or the 3-in-1 blocks. Complete block primarily depends upon whether the obturator nerve is blocked—which may be difficult to obtain and unpredictable (30). The difficulty is that, although injected anesthetic entering the IFC blocks the femoral and LFC nerves, sufficient anesthetic does not always migrate proximally to block the obturator nerve, which, with the genitofemoral nerve, lies on the internal edge of the psoas muscle in a separate plane from the femoral and LFC nerves (31). With the FICB, an early predictor of optimal pain relief for femur fractures is a sensory block of the inner thigh (19). We report two minor complications (local hematomas) of the procedure. There has been only one prior report of a complication after an FICB. Because the injection site is distant from the femoral nerve and vessels, it is much safer than the 3-in-1 block. Reporting one case of a persistent sensory deficit after a post-operative (total hip replacement) FICB when the patient was not in a condition to report paresthesias during the procedure (which should not, in any event, be necessary), the au-
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thors suggested that the sensory deficit may have been due to her surgery, incorrect placement of the needle, or a normal anatomic variant. The problem resolved after 8 days (32). FICB has rarely been used in Emergency Medicine, although the technique is remarkably simple to learn and use. One study demonstrated its effectiveness in prehospital care, although an anesthesiologist who typically staffed ambulances in that system administered the FICB. In our study, the single-injection FICB produced significant benefit by controlling pain far better than standard parenteral medications without any evidence of increased delirium. We also found that it allowed us to obtain a better history from and physical examination of the patient, including more normal vital signs. Analgesic requirements after FICB injection were minimal, far less than normally used, and limited to non-parenteral antiinflammatory agents. The apparent prolonged analgesic effect (8 h) was unexpected, but possibly due to the large fascial space with substantial surrounding muscle mass into which it was injected. The limitation of this study were that, although marked pain diminishment was demonstrated preoperatively, after epidural anesthesia (with sedation) used for many of these patients’ surgeries, they lacked pain sensation for a prolonged period. After awakening from general anesthesia, they experienced some discomfort. These situations, however, are standard practice, and patient outcomes should be similar wherever they are used.
3.
4. 5.
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8. 9.
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11. 12.
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CONCLUSIONS 16.
The FICB is a rapid, effective, safe and easily performed method of achieving excellent pain control in ED patients with hip fractures. Emergency physicians can perform the FICB with standard ED equipment and the procedure is easy to learn. Based on extensive literature that demonstrates its utility, future studies will explore the efficacy of using the FICB for knee and femoral shaft fractures in adults and children. A particular group that might benefit from FICB use is multiple trauma patients with hip, femoral shaft, and knee injuries who would need less systemic and potentially destabilizing analgesics using the FICB.
17.
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