Overview of Ultrasound-Guided Fascia Iliaca Compartment Block
Pain is not something that we enjoy, and managing it effectively is a crucial part of an emergency medical team’s work. Issues like hip fractures and burns to the leg and other injuries often lead to pain in the lower extremities. However, effectively treating this pain can be a challenge due to various factors, including the side effects of some medicines, individual preferences, and specific aspects of a patient’s health that may make certain types of pain medication less appealing.
Pain medications such as opioids can sometimes lead to a slowed or stopped breathing, low blood pressure, changes in mental state, and throwing up. Non-steroidal anti-inflammatory drugs (NSAIDs), on the other hand, may heighten the risk of bleeding and worsen pre-existing stomach issues. Relying on a common over-the-counter pain medication, acetaminophen, alone may not be enough for severe pain. Hip fractures in particular can be extremely painful and are often seen in older adults who may have multiple health issues, further compounding the challenges in managing their pain.
However, a technique called a fascia iliaca compartment block has shown promise. It can provide effective pain relief with fewer side effects. Relatively quick and easy to learn, this technique has been successfully used with high rates of success using ultrasound for guidance. In a study, patients who received this block for hip fracture pain reported a significant decrease in their pain levels, from an average of 8.5 out of 10 to 2.3 at 2 hours after the injection.
This method also reduced the need for morphine. It’s worth noting that the pain relief effect of this technique lasted for about 8 to 10 hours for a single shot block. Furthermore, a controlled study comparing patients who used only morphine with this technique, showed superior pain relief in all measured time points in the group using the block. In fact, the median total morphine consumption in the block group was zero because the pain relief from the block was excellent. Other studies focusing on fractures of the femur and those conducted in emergency departments using ultrasound guidance also reported similar positive outcomes with significant reductions in pain.
Anatomy and Physiology of Ultrasound-Guided Fascia Iliaca Compartment Block
The sensation in your lower leg is controlled by several nerves, including the sciatic nerve, femoral nerve, obturator nerve, and lateral femoral cutaneous nerve. These nerves start at a network in your lower back known as the lumbar plexus. Only the sciatic nerve has an additional contribution from a network in your tailbone area called the sacral plexus.
The femoral nerve, the biggest of the four, can be seen with an ultrasound when doctors need to insert a tube into the femoral vein, a large blood vessel in your groin. This nerve is located close to, and just to the side of, the femoral artery, another large blood vessel. A tissue layer called the fascia iliaca separates these two.
The obturator nerve travels through a muscle in your lower back and wraps around some large blood vessels. It only controls a small section of your leg on the inside. When doctors need to numb the upper leg area, this nerve is sometimes not fully blocked by the anesthetic injection. The lateral femoral cutaneous nerve controls the sensation to the outside part of your thigh. It runs behind a ligament in the groin area. The sciatic nerve controls sensation to the back side of your upper leg. It is not typically affected by anesthetic injections from the front side.
The fascia iliaca, a layer of tissue, is the second layer seen in an ultrasound of the upper leg. It is beneath another tissue layer known as the fascia lata. When doctors can’t see where they’re injecting (a ‘blind’ approach), they can tell they’ve reached the target area when they feel two distinct ‘pops’. The fascia iliaca tissue layer is located in front of three muscles in this area. A muscle called sartorius and the femoral blood vessels sit between the fascia lata and fascia iliaca. Injecting anesthetic into this area (the fascia iliaca block) can numb the femoral, obturator, genitofemoral, and lateral femoral cutaneous nerves.
Why do People Need Ultrasound-Guided Fascia Iliaca Compartment Block
This type of pain-blocking technique may be useful whenever a person experiences painful injuries or needs procedures on the lower part of the body. The areas of the body where this technique is particularly helpful are those that are supplied by the specific nerves mentioned above. It’s a great alternative when using strong painkillers like opioids may not be the best choice or is not allowed for some reason. Moreover, it can also be combined with opioids in situations where it’s tough to manage the pain. This method has proven to be effective in specific situations such as hip fractures, fractures in the long bone of the thigh, and burns.
When a Person Should Avoid Ultrasound-Guided Fascia Iliaca Compartment Block
There are a few reasons why a patient may not be able to have a certain medical procedure:
– If the patient doesn’t agree to the procedure.
– If the patient has a known allergy to local anesthetics, which are medicines used to numb a small area of your body during the procedure.
– If the patient has already had a dose of local anesthetic that is near the maximum safe amount.
– If the patient previously had a type of surgery known as femoral bypass, which reroutes blood flow around a blocked part of a major blood vessel in the leg.
– If the place where the injection needs to be put in has an infection.
– If the patient is on anticoagulants, which are medicines used to prevent blood clots, (this situation doesn’t always stop the procedure but would need to be carefully considered).
Equipment used for Ultrasound-Guided Fascia Iliaca Compartment Block
* A portable ultrasound machine equipped with a device known as a high-frequency transducer, which can generate detailed images of soft tissues in the body
* A surgical pen used for marking body parts before surgery
* Sterile covers for the probe of ultrasound devices
* An antiseptic solution like Chlorhexidine, Betadine, or any other germ-killing solution. This is used to clean the area before the procedure
* A spinal needle or a special kind of needle used for nerve blocks, which are procedures to prevent pain signals from reaching the brain
* A 30-gauge short needle (this refers to the size of the needle)
* A small syringe that can hold up to three milliliters of fluid
* A larger syringe capable of holding 20 to 60 milliliters of fluid
* A type of medication that numbs a large area for a long time. It’s used to prevent the feeling of pain during and after the procedure
* A heart monitor with continuous pulse oximetry. This machine continuously displays the amount of oxygen in your blood and your heart rate
* Intralipid and a plan for handling toxicity from the local anesthetic, which means a reaction or side effect to the medication used
Who is needed to perform Ultrasound-Guided Fascia Iliaca Compartment Block?
Past medical research has shown that certain types of pain relief, known as regional anesthesia, work well when given by both anesthesiologists (doctors who specialize in pain relief) and emergency doctors. More recent research has shown that even doctors-in-training can effectively perform a specific type of regional anesthesia called a ‘fascia iliaca compartment block’, after only a small amount of training. This procedure involves temporarily numbing a part of the body to prevent or relieve pain.
A study in a medical journal called the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine has shown that even prehospital EMS nurses – these are the first healthcare providers to respond to an emergency situation – can successfully perform fascia iliaca compartment blocks using a blind technique. This means they can do the process without using any visual aids like an ultrasound.
Preparing for Ultrasound-Guided Fascia Iliaca Compartment Block
Before starting a procedure called a compartment block, a doctor needs to prepare to ensure the treatment is safe and successful. This includes explaining what is going to happen to the patient in simple language. The doctor should answer all the patient’s questions to make sure they feel comfortable. It’s normal for patients to sign a consent form before the start of the procedure.
If a patient feels nervous, the doctor might give them a small dose of a medicine that helps them relax. This medicine can also help the patient get into the right position for the procedure. Before the treatment starts, the doctor will perform an exam to check the nerves and blood vessels in the patient’s lower leg. This helps to ensure the procedure is safe.
The doctor will also use a special pen to mark the area where they will do the compartment block. All the required tools and supplies will be gathered and set up in the room, ready for the procedure. This preparation helps ensure things go as smoothly as possible.
How is Ultrasound-Guided Fascia Iliaca Compartment Block performed
This text describes a certain medical procedure. The procedure would start by explaining to you what is going to happen and making sure you agree to it in writing. They would then do a detailed check of your nervous system and blood vessels. Then they would set up all the necessary equipment.
A nurse or another doctor would join in and they would give you a mild calming medication if you need it. They use a device that uses sound waves, an ultrasound, to find the nerve bundles in your thigh. They would mark these with a special pen.
Next, they carefully clean the area with an antiseptic solution and cover it with sterile drapes. They would use the ultrasound again to confirm the location. After that, they would numb the area where they will inject you with anesthesia using a very fine needle.
A bigger needle is then filled with a long-lasting anesthetic, special medication to numb you. Your doctor would make sure not to give you too much. They found a mixture of bupivacaine (a numbing medication) and saline (a salt water solution) to be safe and effective for most adults.
They carefully insert this needle into the previously numbed area, and under continuous ultrasound guidance, they advance the needle until it just punctures a tough layer of tissue called the fascia iliaca. They would then make sure to not be inside any blood vessels.
They inject a small amount of the numbing medication and observe a separation of the fascia (a flat sheet of tissue) from the underlying muscles. Your doctor would continue to inject the medication every 5 milliliters to make sure the needle is in the correct place. The medication should flow easily and there shouldn’t be any blood when they check for it. They might sometimes move towards your inner thigh to directly visualize the medication surrounding your femoral nerve using the ultrasound. They would hold the needle in place during this.
They would keep an eye on the monitor to see if your heart rhythm is normal during this procedure. If they notice any problems, they would stop right away. They would also ask you if you feel any signs of too much anesthesia, like feeling light-headed, dizzy, or numbness around your mouth. They would repeat this check after the procedure. If they notice any issues, they would immediately seek additional help.
After the procedure, they would once again check your nerves and blood vessels and document it. Your doctor would note down the time of the procedure and mark the injection site with a surgical marking pen.
Possible Complications of Ultrasound-Guided Fascia Iliaca Compartment Block
Overall, complications from a single fascia iliac compartment block, a type of anesthesia used in certain surgeries, are quite rare. In a study of 63 adults who received this anesthesia in the emergency department, no major complications were found, and only two people developed small localized collections of clotted blood, called hematomas. The procedure was even performed safely by non-doctor nurses in emergency medical services locations without any complications, according to another study of 100 patients.
The risk of injecting the anesthesia drug into a blood vessel or damaging a nerve is significantly reduced because the needle does not have to get very close to any nerves or blood vessels during the procedure. It’s therefore unusual to have instances of the drug going into a blood vessel or causing damage to nerves.
What Else Should I Know About Ultrasound-Guided Fascia Iliaca Compartment Block?
The fascia iliaca compartment block is a type of anesthesia often used in emergency departments. It is highly efficient as it can be given quickly and effectively to relieve pain. This method has minimal side effects, making it a great option for severe pain management.
Fascia Iliaca Compartment Block is a technique where doctors use ultrasound images to guide a needle with medication to numb a specific region in the lower body. This technology helps improve accuracy and makes the process safer. These skills are already utilized by emergency physicians and can be easily applied in urgent care scenarios.
Despite its benefits, this technique is often underused in emergency departments. However, when used, it can provide significant pain relief for a sustained period, improving the comfort and overall experience for the patients.
