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Fascia Iliaca Nerve Block

Welcome to the Fascia Nerve Iliaca Block regional anesthesia page. Here we will cover indications, contraindications, materials and steps for you to master this procedure. Let’s begin with the overview below.

Overview

The fascia iliaca block is a fast and effective method to provide pain relief following trauma or analgesia before or after surgery to the lateral and anterior thigh, including the knee. It can be especially useful in elderly patients, who have a higher incidence of hip fractures and are more prone to adverse effects of IV anesthesia.[1] The fascia iliaca block has been shown to reduce the incidence of nausea, vomiting, delirium, length of stay, and importantly, the amount of parenteral pain medications (opioids) used in these patients.[2][3][4]

Indications

Analgesia for lower extremity trauma, including fractures (hip, femur, patella), and anterior thigh burns.

Contraindications[1][3]

There are few true contraindications to this block. They include:

  1. Infection (cellulitis) at the site of injection
  2. Allergy to local anesthetic being used
  3. Patient refusal

Some relative contraindications to consider:
  1. Patient needs a neural exam of the affected extremity
  2. Anticoagulation use or bleeding disorder (pressure and tourniquet can be applied to the affected area if necessary)
  3. Prior neural lesion or active injury
  4. Previous femoral vascular graft surgery

Anatomy

The femoral nerve and the lateral femoral cutaneous nerve lie under the fascia lata and fascia iliaca, they are easily targeted by a regional block that instill local anesthetic into this area. They are separated from artery and nerve by the fascia iliaca, which decreases the risk for systemic toxicity with this block, so long as the vessels are not injected directly.

Materials

Technique [5][6][7]

Blocks should be performed with aseptic technique using a skin antiseptic, sterile field, and sterile equipment if possible. Allow for appropriate dry time for your antiseptic. Block needles should be aspirated prior to every injection to avoid intravascular administration, and injection should be immediately stopped if the patient suddenly complains of pain or high pressure.

Procedure with step by step process:

  1. Place patient in supine position.
  2. Clean the area with antiseptic solution and drape the area with sterile towels.
  3. Dividing the inguinal crease (from the anterior superior iliac spine to the pubic tubercle) in thirds, place the probe in transverse position in the lateral 1/3.
  4. Identify the femoral nerve just lateral to the femoral artery. Identify the hyperechoic fascia iliaca, superior to the iliacus muscle and surrounding the femoral nerve.
  5. Place a skin wheal at injection site.
  6. Introduce the needle lateral to medial in-plane to the probe and advance the needle to puncture through the fascia iliaca (a “pop” may be felt).
  7. After negative aspiration, inject anesthetic to perform hydro-dissection of the femoral nerve and visualize separation between the fascia iliaca and the iliopsoas muscle.
  8. Continue to inject remaining anesthetic (~30 mL total) and confirm by visualizing expanding anechoic fluid medially and laterally below the fascia iliaca.

     

    Note: The site of injection does not have to be directly around the femoral nerve, especially if the nerve courses in close proximity to the femoral artery. Injection below the fascia iliaca relatively close to the femoral nerve is safer and will provide adequate spread of the local anesthetic under the fascia to the necessary nerves.

Two provider technique:

  1. Connect the extension tubing to the nerve block needle and to the syringe with local anesthetic.
  2. Prime the extension tubing with anesthetic to remove air.
  3. Perform Steps 1-5, as above under “Procedure with step by step process.”
  4. Perform the remaining steps with the first provider positioning the ultrasound probe and nerve block needle, and the second provider aspirating and injecting the anesthetic at the direction of the first provider.

Summary & Bullet Points

  • Fascia iliaca nerve block is a safe and effective way to provide analgesia for lower extremity pain
  • Very little contraindications exist for this block (overlying infection, medication allergy)
  • Volume of administration (~30 mL) is important here, as is targeting deposition of the local anesthetic below the fascia iliaca.
  • Fascia iliaca blocks can reduce opioid consumption and hospital length of stay

    • References

    [1] Pepe J, Ausman C, Madhani NB. Ultrasound-guided Fascia Iliaca Compartment Block. https://www.ncbi.nlm.nih.gov/books/NBK518973/. Jan 2022.

    [2] Wan HY, Li SY, Ji W, Yu B, Jiang N. Fascia Iliaca Compartment Block for Perioperative Pain Management of Geriatric Patients with Hip Fractures: A Systematic Review of Randomized Controlled Trials. Pain Res Manag. 2020 Nov 25;2020:8503963. [Pubmed].

    [3] Makkar JK, Singh NP, Bhatia N, Samra T, Singh PM. Fascia iliaca block for hip fractures in the emergency department: meta-analysis with trial sequential analysis. Am J Emerg Med 2021;50:654-60. [Pubmed].

    [4] Shyy, W. Fascia iliaca nerve block: A hip fracture best-practice. https://www.aliem.com/fascia-iliaca-nerve-block/. Feb 2022.

    [5] WikEM contributors. Nerve Block: Fascia Iliaca Compartment. WikEM, The Global Emergency Medicine Wiki. May 8, 2021. Available at: https://wikem.org/wiki/Nerve_Block:_Fascia_Iliaca_Compartment. Accessed January 2022.

    [6] Atchabahian A, Leunen I, Vandepitte C, Lopez AM. “Ultrasound-Guided Fascia Iliaca Nerve Block.” Available at: https://www.nysora.com/regional-anesthesia-for-specific-surgical-procedures/lower-extremity-regional-anesthesia-for-specific-surgical-procedures/ultrasound-guided-fascia-iliaca-block/. Accessed January 2022.

    [7] Jeng CL, Rosenblatt MA. “Lower Extremity Nerve Blocks: Techniques.” Available at www.uptodate.com. Accessed January 2022.

    Resource Libaray

    Fascia Iliaca Nerve Block

    Welcome to the Fascia Nerve Iliaca Block regional anesthesia page. Here we will cover indications, contraindications, materials and steps for you to master this procedure. Let’s begin with the overview below.

    Overview

    The erector spinae is actually a group of muscles involved in maintaining an upright posture and rotating the back. The muscle group is composed of the iliocostalis, longissimus, and spinalis muscles.[1] These muscles run from the spinous process of the vertebrae out laterally to the transverse process and have connections on the ipsilateral ribs as well. The block is a fascia block, with deposition ideally under the fascia of the erector spinae muscle. This block is used for a variety of painful conditions of the torso.[2] While its exact mechanism is not clearly understood, it is thought to likely work by interfascial spread of local anesthetic toward the posterior rami of spinal nerves. In Emergency Medicine, it is commonly used for post-traumatic pain or to facilitate procedures such as chest tube placement.

    Indications

    Analgesia for lower extremity trauma, including fractures (hip, femur, patella), and anterior thigh burns.
    There are few true contraindications to this block. They include:
    • Infection (cellulitis) at the site of injection
    • Allergy to local anesthetic being used
    • Patient refusal
    Some relative contraindications to consider:
    • Patient needs a neural exam of the affected extremity
    • Anticoagulation use or bleeding disorder (pressure and tourniquet can be applied to the affected area if necessary)
    • Prior neural lesion or active injury
    • Previous femoral vascular graft surgery

    Anatomy

    The femoral nerve and the lateral femoral cutaneous nerve lie under the fascia lata and fascia iliaca, they are easily targeted by a regional block that instill local anesthetic into this area. They are separated from artery and nerve by the fascia iliaca, which decreases the risk for systemic toxicity with this block, so long as the vessels are not injected directly.

    Materials

    Note: Bupivacaine or ropivacaine are local anesthetics of choice given their longer duration of action. Bupivacaine has a maximum dose of ~2.5 mg/kg. The fascia iliaca block is all about volume, so the .25% concentration of bupivacaine is great here because it contains 2.5 mg/mL. So the max dose ends up being the patient’s weight in kilograms. (Ex 70 kg male: 70 kg x 2.5 mg/kg = 175 mg. 175 mg / 2.4 mg/mL= 70 mL). You are targeting a volume of ~30 mL. If using a higher concentration local anesthetic, the sterile saline is included for the potential need for dilution to reach 30 mL.

    Technique [5][6][7]

    Blocks should be performed with aseptic technique using a skin antiseptic, sterile field, and sterile equipment if possible. Allow for appropriate dry time for your antiseptic. Block needles should be aspirated prior to every injection to avoid intravascular administration, and injection should be immediately stopped if the patient suddenly complains of pain or high pressure.

    Procedure

    Procedure with step by step process:

    Place patient in supine position.

    Clean the area with antiseptic solution and drape the area with sterile towels.

    Dividing the inguinal crease (from the anterior superior iliac spine to the pubic tubercle) in thirds, place the probe in transverse position in the lateral 1/3.

    Identify the femoral nerve just lateral to the femoral artery. Identify the hyperechoic fascia iliaca, superior to the iliacus muscle and surrounding the femoral nerve.

    Place a skin wheal at injection site.

    Introduce the needle in-plane to the probe and advance the needle to puncture through the erector spinae muscle over the transverse process.

    After negative aspiration, inject anesthetic to perform hydro-dissection of the femoral nerve and visualize separation between the fascia iliaca and the iliopsoas muscle.

    Continue to inject remaining anesthetic (~30 mL total) and confirm by visualizing expanding anechoic fluid medially and laterally below the fascia iliaca.

    Two provider technique:

    Connect the extension tubing to the nerve block needle and to the syringe with local anesthetic. Prime the extension tubing with anesthetic to remove air. Perform Steps 1-5, as above under “Procedure with step by step process.” Perform the remaining steps with the first provider positioning the ultrasound probe and nerve block needle, and the second provider aspirating and injecting the anesthetic at the direction of the first provider.

    Summary & Bullet Points

    • Fascia iliaca nerve block is a safe and effective way to provide analgesia for lower extremity pain
    • Very little contraindications exist for this block (overlying infection, medication allergy)
    • Volume of administration (~30 mL) is important here, as is targeting deposition of the local anesthetic below the fascia iliaca.
    • Fascia iliaca blocks can reduce opioid consumption and hospital length of stay

    References

    [1] Pepe J, Ausman C, Madhani NB. Ultrasound-guided Fascia Iliaca Compartment Block. https://www.ncbi.nlm.nih.gov/books/NBK518973/. Jan 2022.

    [2] Wan HY, Li SY, Ji W, Yu B, Jiang N. Fascia Iliaca Compartment Block for Perioperative Pain Management of Geriatric Patients with Hip Fractures: A Systematic Review of Randomized Controlled Trials. Pain Res Manag. 2020 Nov 25;2020:8503963. [Pubmed].

    [3] Makkar JK, Singh NP, Bhatia N, Samra T, Singh PM. Fascia iliaca block for hip fractures in the emergency department: meta-analysis with trial sequential analysis. Am J Emerg Med 2021;50:654-60. [Pubmed].

    [4] Shyy, W. Fascia iliaca nerve block: A hip fracture best-practice. https://www.aliem.com/fascia-iliaca-nerve-block/. Feb 2022.

    [5] WikEM contributors. Nerve Block: Fascia Iliaca Compartment. WikEM, The Global Emergency Medicine Wiki. May 8, 2021. Available at: https://wikem.org/wiki/Nerve_Block:_Fascia_Iliaca_Compartment. Accessed January 2022.

    [6] Atchabahian A, Leunen I, Vandepitte C, Lopez AM. “Ultrasound-Guided Fascia Iliaca Nerve Block.” Available at: https://www.nysora.com/regional-anesthesia-for-specific-surgical-procedures/lower-extremity-regional-anesthesia-for-specific-surgical-procedures/ultrasound-guided-fascia-iliaca-block/. Accessed January 2022.

    [7] Jeng CL, Rosenblatt MA. “Lower Extremity Nerve Blocks: Techniques.” Available at www.uptodate.com. Accessed January 2022.