|Year : 2021 | Volume
| Issue : 4 | Page : 191-195
Comparison of two ultrasound-guided approaches for the fascia iliaca compartment block in patients with a proximal femur fracture
Suvir Dubey1, Uday Ambi2, Priya Taank3, Shalendra Singh4, Subhasish Patnaik4, Bhawna Hooda5, Shibu Sasidharan6
1 Safdarjung Hospital and VM Medical College, New Delhi, India
2 Kings College Hospital London, Dubai
3 Department of Ophthalmology, Command Hospital (SC), Pune, Maharashtra, India
4 Department of Anaesthesiology and Critical care, Armed Forces Medical College, Pune, Maharashtra, India
5 Department of Anaesthesiology and Critical care, Command Hospital (SC), Pune, Maharashtra, India
6 Department of Anaesthesiology and Critical care, Command Hospital (WC), Chandigarh, Haryana, India
|Date of Submission||04-Jun-2021|
|Date of Decision||12-Jul-2021|
|Date of Acceptance||09-Jan-2022|
|Date of Web Publication||11-Jan-2022|
Department of Anaestheiology and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra,
Source of Support: None, Conflict of Interest: None
Background: Fascia iliaca compartment block (FICB) is a popular block in patients with hip injuries. It gives good postinjury analgesia and helps in positioning for neuraxial blockade before the surgery. Aims and Objectives : The study aims to compare two approaches (parallel versus perpendicular) of ultrasound (USG)guided FICB in patients undergoing proximal femur fracture surgeries. The primary objective was to compare the time to do ultrasonic imaging, time to perform the FICB, and total block time. The secondary objective was to compare the time to loss of sensation, first rescue analgesia, pain score and occurrence of adverse events. Materials and Methods: Fiftyone patients were allocated into two groups in this prospective observational study. In parallel group (Group A) (n = 25), the USG probe was kept parallel to the inguinal ligament, and in the perpendicular group (Group B) (n = 26), a probe was placed perpendicular to the inguinal ligament. Both groups received equal doses of the drug. The time to achieve ultrasonic imaging, time to perform the block, total block time, loss of sensation within the distribution of lateral cutaneous nerve and the femoral nerve was noted. Time to first rescue analgesia, pain score and adverse events were also noted. Results: Group A approach was quicker to perform than the perpendicular approach (5.1 ± 0.7 vs. 7.3 ± 1.2 min) (P < 0.0001). The imaging time of Group A was shorter than Group B (3.2 ± 0.3 vs. 5.3 ± 0.7 min) (P < 0.0001). The success rate of sensory loss of lateral cutaneous nerve was quicker and better with Group B (88% vs. 100%). No statistical differences were noted in postoperative pain score, time of rescue analgesia, the incidence of complications, and the patient's satisfaction score between the two groups. Conclusion: The perpendicular approach of USGguided FICB may offer a better blocking effect of lateral cutaneous nerve and longer duration of block time, but the parallel approach offers better and quicker ultrasonic imaging.
Keywords: Fascia iliaca compartment block, fracture femur, neuraxial blockade, ultrasound-guided, visual analogue score
|How to cite this article:|
Dubey S, Ambi U, Taank P, Singh S, Patnaik S, Hooda B, Sasidharan S. Comparison of two ultrasound-guided approaches for the fascia iliaca compartment block in patients with a proximal femur fracture. Hamdan Med J 2021;14:191-5
|How to cite this URL:|
Dubey S, Ambi U, Taank P, Singh S, Patnaik S, Hooda B, Sasidharan S. Comparison of two ultrasound-guided approaches for the fascia iliaca compartment block in patients with a proximal femur fracture. Hamdan Med J [serial online] 2021 [cited 2022 Jan 20];14:191-5. Available from: http://www.hamdanjournal.org/text.asp?2021/14/4/191/335379
| Introduction|| |
The fascia iliaca block also known as fascia iliaca compartment block (FICB) is a popular block in patients with hip injuries. Hip fractures are common in frail and elderly populations with multiple co-morbidities., These patients will require adequate analgesia post-injury and for positioning for neuraxial blockade before the surgery. Although there are conventional methods of analgesia like the use of non-steroidal anti-inflammatory drugs (NSAIDs), opioids use, nerve blocks like 3 in 1 block, femoral nerve block, FICB is one of the most preferred techniques.
FICB is not a nerve block, but a single shot compartment block in which a large volume of local anaesthetic agent is injected beneath fascia iliaca which cover femoral nerve on the medial side, lateral femoral cutaneous nerves (LCNs) on the lateral side, and a short course of obturator nerve in the deeper plane. Ultrasound (USG)-guided regional blocks are gaining popularity as it shortens block onset time, increases success rates and reduces the number of needle insertions, complications. Studies have shown that the success rate increases from 32% to 47% when we compare the pop technique to the real-time USG technique. Although some studies are comparing the landmark versus USG-guided FICB, few have compared two different approaches of USG-guided FICB inpatient with hip fractures.
This study has been conducted to compare the in-plane and out-of-the-plane techniques of USG-guided FICB.
| Materials and Methods|| |
This prospective observational study was consorted at a tertiary care hospital. Before the start of the study, ethical clearance was obtained from the institutional ethics committee (SNMC/IECHSR/2014-15/A-16a-1.1, Bagalkot, India, Date 11 November, 2014), and written informed consent was obtained from the patients. A total of 51 patients undergoing surgery for fracture of the proximal femur in the American society of anaesthesiology physical status I and II, between 18 and 80 years were enrolled in this study. Patients with bleeding disorders, patients on previous opioid use, allergy to local anaesthetics, peripheral neuropathy, hepatic or renal insufficiency, inguinal hernia, inflammation or infection nearby injection site, previous femoral bypass surgery, morbid obesity, psychiatric disorders, poly-trauma were excluded from the study.
Applying consecutive sampling method, first 25 patients who were accomplish study inclusion criteria were given FICB by using USG in parallel (Group A) and the other 26 patients were given block by using USG probe in the perpendicular direction (Ggroup B) to the inguinal ligament [Figure 1] and [Figure 2]. Both groups received the same dose of 40 ml of 0.375% ropivacaine 30 min before the administration of the subarachnoid block. Vitals were recorded by the blinded treating clinician. Anaesthesia resident noted the time to achieve the ultrasonic imaging, time to perform the block, loss of sensation in the distribution areas of lateral cutaneous nerve and femoral nerve. A 22G 100 mm needle (Stimuplex®, B. Braun, Melsungen, Germany), SonositeMicromax® (Sonosite®, Bothell, WA, USA) was used for the study. A simple 10-point Visual Analogue Scale (VAS) to assess the severity of pain was recorded before and 6 h after block. Hollmen scale was used to assess the sensory blockade (Grade 1-full sensation, Grade 2-weak sensation, Grade 3-Recognised as light touch, Grade 4-Loss of sensation). Each Patient was monitored using electrocardiography, pulse oximetry (SpO2), and non-invasive blood pressure. Satisfaction while positioning for spinal anaesthesia (SA) was pointed 30 min after FICB using the VAS score. Post-operative monitoring data have done every 15 min for the first half-hour than every 30 min following that until the 6th post-operative h. Rescue analgesia as tramadol (100 mg) was given to patients who had pain scores of 4 and above.
|Figure 1: Showing patient given fascia iliaca compartment block by using ultrasound in parallel direction to the inguinal ligament|
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|Figure 2: Showing patient given fascia iliaca compartment block by using ultrasound in perpendicular direction to the inguinal ligament|
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Based on the previous trial, the sample size was determined using OPEN-EPI version 2.3.1 software, Massachusetts. The sample size came to be 13 in each group. However, we have taken 25 patients in each group. Statistical analysis was performed using SPSS software 19.0 (statistical analysis in social science,Chicago, Illinois). Data were arranged in the excel sheet and analysed. The values were expressed as mean + standard deviation. The Student's unpaired t-test was used to analyse the quantitative data. P < 0.05 was considered statistically significant.
| Results|| |
In this study, an entire of 67 patients were admitted during the study period (January 2015 to June 2017) in which nine patients unsuited in inclusion criteria, two patients conveyed their reluctance to take part in the study and five patients were excluded because of unavailability of the investigator (SS). Demographic data were comparable in both groups [Table 1]. Most of the patients were of 51–70 years of the age range (nearly 70%). Group B had a pre-dominantly female population.
The parallel to the inguinal canal approach was quicker to perform than a perpendicular approach (5.1 ± 0.7 vs. 7.3 ± 1.2 min) (P < 0.0001) [Figure 1]. The imaging time of Group A was shorter than Group B (3.2 ± 0.3 vs. 5.3 ± 0.7 min) (P < 0.0001) [Figure 3]. The success rate of lateral cutaneous nerve sensory loss was quicker and better with Group B (88% vs. 100%) (Sensory block Grade-3). Three patients had a dull sensation analgesia block (sensory block Grade-2) over lateral cutaneous nerve territory in Group A. The mean heart rate (HR) was comparable in both groups [Table 2]. The Student's unpaired t-test showed that after 30 min of the block, the HR was comparable in both the groups. After the first 30 min of giving FICB block, there was no significant variation in the systolic blood pressure (SBP) in between the groups (P > 0.05). The entire value of diastolic blood pressure (DBP) was notable underneath in group B as correlate to the group prior to the block, but the variation of DBP with time was not significant [Table 2]. SpO2 was maintained throughout the study period.
|Figure 3: Left-handed image showing imaging timings and time are taken to loss of sensation in femoral and lateral cutaneous nerve and right-handed showing total block time and rescue analgesia in both groups|
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|Table 2: Haemodynamic parameters and Visual Analogue Score at different time intervals (values expressed as mean±standard deviation or number) during the observation period in two groups|
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A gradual improvement of pain score from a mean of 7.40 in Group A and 7.35 in Group B before the block to a score of 2 at the end of 30 min was noted. It was attained before time in Group B contrast to Group A, although the difference was not significant. Haemodynamic variables such as HR, SBP, DBP, SpO2 values were comparable in both groups. No patients in either group needed any intervention both preoperatively and postoperatively. No statistical difference was noted in post-operative pain score, time of rescue analgesia, the incidence of complications, and the patient's satisfaction score between the two groups [Figure 1].
| Discussion|| |
With the advancement in medical sciences, the ageing populations in our society are rising, so is the probability of having more traumatic hip fractures in frail and older populations. Hip fractures are linked with significant pain, especially in the geriatric population; a good analgesia technique is much required. Unfortunately, pain management in elderly people is difficult due to medication side effects, a patient characteristic that makes NSAIDs a less preferable choice. Opioid preparations have been associated with respiratory depression, hypotension, and vomiting and mental status changes. A FICB in these cases is considered a good choice with minimal side effects. A study by Godoy Monzon et al. showed that patients who received FICB after hip fractures showed significant pain relief. A randomised controlled study by Stevens et al. suggested that patients who underwent FICB received a significant amount of less morphine over 24 h as compared to the control group who received morphine alone. Elderly persons with fracture femur are more susceptible to delirium because of medications and pain. Appropriate analgesia in such patients averts delirium and averts mobility and associated with the shorter hospital stay. This block provides adequate pain relief and patients are comfortable during positioning for the neuraxial blockade.,, Analgesia provided by FICB and femoral nerve blocks are comparable with epidural analgesia, with a lower incidence of hypotension.
We preferred FICB block in these surgeries because it is added efficacy in blocking the lateral cutaneous nerve of the thigh and femoral nerve. It is easily accomplished task and is correlated with the slightest risk as the local anaesthesia agent is injected at a safer distance from the femoral artery. It is always preferred to perform the FICB before SA as the response of the patient during the administration of the local anaesthetic can be distinguished and it can abort intraneuronal injections. There have been reports suggesting post-operative neuropathy when FICB was given after SA. Apart from injection pressure monitoring, USG guidance also prevents intraneural injection due to real-time imaging of the needle and nerve. A randomised controlled study by Dolan et al. suggested a higher success rate with USG-guided FICB as compared to the loss of resistance study.
In our study, we compared the two approaches of USG probe placement and found out that although there is less amount time taken in locating the USG imaging and administration of the drug in parallel method, the perpendicular method showed significantly quicker and extended hypoesthesia over the distribution area of the lateral cutaneous nerve. The parallel-group is the most popular approach to USG guided FICB but it sometimes does not provide complete sensory blockade of lateral cutaneous nerve. In a case study by Ueshima and Otake, the suprainguinal approach helped in the better blockade of the lateral cutaneous curve. Fascia iliaca block involves blockade of both the femoral nerve and LCN. LCN may branch proximally to the anterior superior iliac spine. The perpendicular approach helps in the better spread of local anaesthestic suprainguinally thus blocking the LCN also. A study by Wang Ning et al. on the patient undergoing hip arthroplasty showed similar results to our study. The probable justification for a better block by perpendicular approach is the suprainguinal spread of the drug and the amount of drug can also be reduced in that approach. However, further studies are required to establish the best approach to FICB.
| Conclusion|| |
Our study suggested that USG-guided FICB given in either approach before SA would ensure patient comfort during positioning for SA and also provide good post-operative analgesia without haemodynamic instability. However, the perpendicular approach of USG-guided FICB has a better block effect as compared to the parallel method. Although the parallel approach took lesser time to locate the ultrasonic imaging and performance of the block, further comparative studies are required to establish a better approach to perform such block.
The study was approved by the institutional Ethics Committee of S.Nijalingappa Medical College, Navanagar, Bagalkot, India. (Approval No SNMC/IECHSR/2014-15/A-16a-1).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]