ANALGESIA FOR THE PERFORMANCE OF SPINAL
ANAESTHESIA IN SITTING POSITION IN THE PATIENTS
WITH PROXIMAL FEMORAL FRACTURE-A COMPARISON
BETWEEN ULTRASOUND GUIDED FASCIA ILIACA BLOCK
AND FEMORAL NERVE BLOCK
DISSERTATION SUBMITTED FOR THE DEGREE OF DOCTOR
OF MEDICINE
BRANCH – X (ANAESTHESIOLOGY)
REG.NO.201720106
THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY
CHENNAI, TAMILNADU
MAY-2020
CERTIFICATE BY GUIDE
INSTITUTE OF ANAESTHESIOLOGY AND CRITICAL CARE
This is to certify that this dissertation entitled “ANALGESIA FOR
THE PERFORMANCE OF SPINAL ANAESTHESIA IN SITTING
POSITION IN THE PATIENTS WITH PROXIMAL FEMORAL
FRACTURE- A COMPARISON BETWEEN ULTRASOUND
GUIDED FASCIA ILIACA BLOCK AND FEMORAL NERVE
BLOCK” is a bonafide and genuine research work done by
DR.M.NISHANTHI in partial fulfillment of the requirement for the
degree of MD in Anaesthesiology and Critical care.
Dr.R.KAVITHA. M.D.,
Assistant Professor
Institute of Anaesthesiology
Madurai Medical College
Madurai-20
DR.R. SELVAKUMAR M.D., D.A., D.N.B
Professor
Institute of Anaesthesiology
Madurai Medical College
Madurai-20
Date:
Place:
CERTIFICATE BY HEAD OF THE DEPARTMENT
INSTITUTE OF ANAESTHESIOLOGY AND CRITICAL CARE
This is to certify that this dissertation entitled “ANALGESIA FORTHE
PERFORMANCE OF SPINAL ANAESTHESIA IN SITTING
POSITION IN THE PATIENTS WITH PROXIMAL FEMORAL
FRACTURE- A COMPARISON BETWEEN ULTRASOUND
GUIDED FASCIA ILIACA BLOCK AND FEMORAL NERVE
BLOCK” is a bonafide and genuine research work done by
Dr.M.NISHANTHI in partial fulfillment of the requirement for the degree
of MD in Anaesthesiology and Critical care under the guidance of
Prof.Dr.R.SELVAKUMAR M.D., D.A., DNB Institute of
Anaesthesiology and critical care.
DATE :
PLACE: Madurai
Prof.Dr.M. KALYANASUNDARAM M.D.,
Director,
Institute of Anaesthesiology,
Govt. Rajaji Hospital & Madurai Medical College
Madurai.
ENDORSMENT BY THE DEAN
GOVERNMENT RAJAJI MEDICAL COLLEGE AND HOSPITALS
This is to certify that this dissertation entitled “ANALGESIA FOR THE
PERFORMANCE OF SPINAL ANAESTHESIA IN SITTING
POSITION IN THE PATIENTS WITH PROXIMAL FEMORAL
FRACTURE- A COMPARISON BETWEEN ULTRASOUND
GUIDED FASCIA ILIACA BLOCK AND FEMORAL NERVE
BLOCK” is a bonafide and genuine research work done by
Dr.M.NISHANTHI in partial fulfillment of the requirement for the degree
of MD in Anaesthesiology and Critical care under the guidance of
Prof.Dr.R.SELVAKUMAR M.D.,D.A.,D.N.B Institute of
Anaesthesiology and critical care, Professor, Institute of Anaesthesiology
and critical care.
Date:
DR.K. VANITHA M.D.,DCH Place: Madurai Dean
Govt. Rajaji Hospital
Madurai Medical College
Madurai.
DECLARATION
I, Dr.M.NISHANTHI solemnly declare that, this dissertation titled
“ANALGESIA FOR THE PERFORMANCE OF SPINAL
ANAESTHESIA IN SITTING POSITION IN THE PATIENTS
WITH PROXIMAL FEMORAL FRACTURE- A COMPARISON
BETWEEN ULTRASOUND GUIDED FASCIA ILIACA BLOCK
ANDFEMORAL NERVE BLOCK” has been done by me. I also
declare that this bonafide work or a part of this work was not submitted by
me or any other for any award, degree or diploma to any other University
or board either in India or abroad.
This is submitted to The Tamilnadu DR.M.G.R Medical University,
Chennai in partial fulfillment of the rules and regulations for the award of
Doctor of Medicine degree branch X (Anaesthesiology) to be held in MAY
2019.
Date:
Place: Madurai Dr.M.NISHANTHI
ACKNOWLEDGEMENTS
With great reverence, I extend my deep sense of gratitude to
respected guide Dr.R.Selvakumar M.D.,D.A.,D.N.B., Professor,
Institute of Anaesthesiology and critical care, for his advice, able
guidance, constant inspiration, constructive criticism and novel
suggestions throughout my post graduate study, without whose initiative
and enthusiasm, this study would not been completed.
My sincere thanks to Dr.M.KALYANASUNDARAM M.D.,
DIRECTOR, Institute of Anaesthesiology and critical care who supported
and guided me in each and every step of my work.
My sincere thanks to Dr.R.KAVITHA M.D., Assistant Professor,
Institute of Anaesthesiology and critical care who supported and guided
me in each and every step of my work.
I am thankful to all my Assistant Professors, Professors, My
Colleagues, Seniors, Juniors and All Other Staff Members Institute of
Anaesthesiology And Critical Care for their constant support and guidance
in completing this study.
I thank my Parents and Family members for their support during the
course of study.
I also thank my collaborating department, Department of
orthopedic surgery who allowed me to perform my study at their theatre.
I thank The Dean, Government Rajaji Hospital and Madurai
Medical College, Madurai for permitting me to utilize the college and
hospital for my study. Lastly, I sincerely thank all of my patients for their
kind cooperation during the course of the study.
Date:
Place: Madurai Dr.M.NISHANTHI
TABLE OF CONTENT
S.NO TITLE PAGE NO
1. INTRODUCTION 1
2. CLINICAL ANATOMY-LUMBAR PLEXUS 2
3. FEMORAL NERVE 9
4. FASCIA ILIACA COMPARTMENT 14
5 CLINICAL PHARMACOLOGY LIGNOCAINE 17
6 CLINICAL PHARMACOLOGY BUPIVACAINE 19
7 ULTRASONOGRAM 22
5. FASCIA ILIACA COMPARTMENT BLOCK 29
6. FEMORAL NERVE BLOCK 36
7. SPINAL ANAESTHESIA 42
8. REVIEW OF LITERATURE 49
9. AIM OF STUDY 57
10. MATERIALS AND METHODS 58
11. STATISTICAL ANALYSIS 61
12. OBSERVATION 62
13. RESULTS 74
14. DISCUSSION 75
15. CONCLUSION 78
16. BIBILIOGRAPHY 79
17. ANNEXURES
81 1.PROFORMA
2.MASTER CHART
3.ETHICAL CLEARANCE
4.PLIAGRASIM CERTIFICATE
1
INTRODUCTION
Fracture of the femur occurs most commonly after trauma or trivial
fall especially in the elderly. This causes significant morbidity. Surgery for
fracture femur may be done under regional or general anesthesia. It has
been shown that regional anesthesia is associated with lesser morbidity and
mortality compared to general anesthesia.
Regional anesthesia was associated with a lower adjusted odds of
mortality compared to general anesthesia. Thus, femur fracture surgeries
are performed safely under regional anesthesia. Subarachnoid block is
administered in either the sitting or lateral position. Positioning patients for
spinal anesthesia with fractured femur is challenging because even
minimal overriding of the fracture ends is exceedingly painful.
Providing analgesia before positioning not only increases patient
comfort but also improves positioning and successful spinal block. So this
study is conceived to compare the efficacy of two different block for
providing analgesia during positioning for spinal anaesthesia.
2
CLINICAL ANATOMY
Since femoral nerve and obturator nerve, lateral cutaneous nerve
originate from lumbar plexus. First this chapter explains about lumbar
plexus.
LUMBAR PLEXUS:
The lumbar plexus is formed by upper four lumbar nerves. After
emerging from the intervertebral foramina each nerve divides into dorsal
ramus and ventral ramus. Dorsal rami of lumbar plexus supplies cutaneous
nerve supply to gluteal region. The ventral rami enter the substance of the
psoas major muscle, within the muscle the rami from the upper 4 lumbar
nerves join each other to form the lumbar plexus. Part of 4th lumbar nerve
joins the 5th lumbar to form the lumbosacral trunk, which takes part in
forming the sacral plexus. The greatest part of the 1st lumbar nerve is
continued into a nerve trunk that divides into iliohypogastric and
ilioinguinal nerve. The rest of the 1st lumbar nerve is joined by a branch
from 2nd lumbar to form the genitofemoral nerve. The 2nd ,3rd and greater
part of the 4th lumbar nerve divides into anterior and posterior division. The
posterior division which are large form the femoral nerve. The posterior
divisions of L2 and L3 also gives rise to lateral cutaneous nerve of thigh.
The anterior division unites to form the obturator nerve . Other branches
are to Psoas major(L2-L3), Quadratus lumborum T12,L1,L2,L3, Psoas
minor L1 and Iliacus L2,L3.
3
LUMBAR PLEXUS:
4
LATERAL CUTANEOUS NERVE OF THIGH
The lateral cutaneous nerve of thigh is derived from the dorsal
divisions of L2 L3 , intial part lies within the psoas major . Emerging from
the lateral border of the muscle the nerve runs downwards, laterally and
forward over the iliacus muscle to reach the anterior superior iliac spine. It
enters thigh by passing behind lateral end of inguinal ligament. It divides
into anterior and posterior branches through which it supplies the skin on
the anterolateral part of the thigh right up to the knee. While the nerve is
over the iliacus muscle, it is related to the caecum on the right side and to
the part of descending colon on the left side.
5
OBTURATOR NERVE
This nerve is formed by union of roots arising from L2, L3, and L4 .Its
course can be considered in three parts.
1. The first part runs downwards in the substance of the psoas major.
2. The second part of the nerve lies in the lateral wall of the true pelvis.
It runs downwards and forwards lying over the obturator internus
muscle.
3. The third part of the nerve lies in the thigh. As it passes through the
obturator foramen, it divides into anterior and posterior divisions
The anterior division lies in front of the obturator externus (above) and
the adductor brevis (below): It lies behind the pectineus (above) and the
adductor longus (below).
The posterior division lies in front of the obturator externus (above)
and the adductor magnus (below). It is behind the pectineus (above) and
the adductor brevis (below).
Muscular branches
Branches arising from the anterior division supply:
a. Obturator externus
b. Adductor longus
c. Gracilis
d. Pectineus and the adductor brevis (sometimes).
6
Branches of the posterior division supply:
a. Obturator externus
b. Adductor brevis
c. Adductor magnus.
Cutaneous branches
Anterior division supplies the skin of the lower medial part of the
thigh.
Articular branches
These are given off to the hip joint and to the knee joint. The latter
is a continuation of the posterior division and travels along the femoral
artery.
Vascular branches
The anterior division supplies the femoral artery.
7
OBTURATOR NERVE
8
ACCESSORY OBTURATOR NERVE
Arising from L2 and L3 this nerve runs downwards along medial
margin of Psoas major in company with the external iliac vessels. It does
not enter the true pelvis, but passes behind the inguinal ligament deep to
the pectineus to reach the thigh. The nerve ends by supplying the pectineus
and the hip joint and communicates with the anterior division of the
obturator nerve
9
FEMORAL NERVE
The femoral nerve arises from the ventral rami of L2, L3 and L4
within substance of the psoas major. Course begins with it descends
through and emerges from the lateral border above the inguinal ligament
.Then it now comes to lie in the groove between iliacus and psoas .In this
position, it passes behind the inguinal ligament to enter the thigh. Then, it
lies lateral to the femoral artery. After a short course it ends by dividing
into anterior and posterior divisions.
Muscular Branches
1. In the abdomen, it gives branches to the iliacus muscle.
2. Then little above inguinal ligament, the femoral nerve gives branch to
the nerve to the pectineus. The nerve passes downwards and medially
behind the femoral vessels to reach pectineus.
3. The anterior division of the femoral nerve supplies the sartorius
4. The posterior division supplies:
a. The rectus femoris c. The vastus medialis
b. The vastus lateralis d. The vastus intermedius
10
BRANCHES
11
CUTANEOUS BRANCHES
1. The anterior division gives the intermediate cutaneous nerve of the
thigh
a. Supplies a broad strip of skin on the front of thigh.
b. Lower end of front knee.
2. The anterior division also gives medial cutaneous nerve of the thigh
a. It lies along lateral side of the femoral artery which it crosses near
apex of the triangle.
b. It divides into branches and supplies the skin of the medial side of
the thigh.
c. The nerve takes part in subsartorial plexus (along with branches of
the saphenous and obturator nerves).
3. The posterior division gives saphenous nerve
a. Descends along the lateral of the femoral artery.
b. In adductor canal, the nerve crosses the artery from lateral side to
medial side of femoral artery.
c. It leaves hunter’s canal at its lower end and runs down along the
medial side of the lower knee. Here, it pierces deep fascia and becomes
subcutaneous.
d. Then runs down medial side of the leg along the long saphenous vein.
A branch extends with medial side of the foot but ends short of the great
toe.
e. The saphenous nerve takes part in subsartorial plexus and the patellar
plexus.
12
FEMORAL NERVE CUTANEOUS SUPPLY
13
Articular Branches
1. The posterior division of the femoral nerve sends fibres to the knee joint
through the nerve to the vastus medialis.
2. Some minor fibres reach the hip joint through the nerve to the rectus
femoris.
14
THE FASCIA ILIACA
It spans from lower thoracic vertebrae to the anterior thigh
It lines posterior abdomen and pelvis and covers iliacus and psoas
muscles
Forms posterior wall of femoral sheath and cover femoral vessels
It is covered by fascia lata in femoral triangle.
ATTACHMENTS:
Throcolumbar fascia attached laterally
Medially attached by vertebral column, pectineal fascia
Anteriorly by posterior part of inguinal ligament
NEUROVASCULAR RELATIONS
Femoral vessels lie superficial to the fascia iliaca above the inguinal
ligament. Behind inguinal ligament the area is divided into medial and
lateral parts.
Fascia iliaca forms the posterior wall of the femoral sheath medially
It forms the roof of the lacuna musculorum laterally, contains psoas
major, iliacus and femoral nerve
15
THE FASCIA ILIACA COMPARTMENT
It is a potential space
Anteriorly: Posterior surface of the fascia iliaca, which covers the
iliacus muscle, and the psoas major muscle.
Posteriorly: anterior surface of iliacus and psoas major.
Medially: vertebral column,
Cranio laterally- by the inner lip of iliac crest.
Cranio-medially – forms the space between quadratus lumborum and
its fascia.
Deposition of local anaesthetics of this compartment allows spread to
major nerves that supply the medial, anterior and lateral thigh
16
FASCIA ILIACA COMPARTMENT
17
LIGNOCAINE
Lignocaine an aminoethyl amide an amide group local anaesthetic.
Introduced in 1948
Most widely used local anaesthetic and also an antiarrhythmic agent.
Lidocaine produces faster, more intense, longer-lasting, and more
extensive anesthesia than does an equal concentration of procaine.
It blocks the nerve conduction by decreasing the entry of sodium
ions during the upstroke of action potential.
Once the concentration of local anesthetics increases the rate of rise
of action potential and the maximum depolarization decreases
causing slowing of conduction. Hence local depolarization doesn’t
reach the threshold potential and conduction block ensues.
Lidocaine is absorbed rapidly after parenteral administration and
from the GI and respiratory tracts.
Lidocaine is dealkylated in the liver by CYPs to monoethylglycine
xylidide and glycine xylidide, which can be metabolized further to
monoethylglycine and xylidide.
18
Both monoethylglycine xylidide and glycine xylidide retain local
anesthetic activity.
About 75% of the xylidide is excreted in the urine as the further
metabolite 4-hydroxy-2,6-dimethylaniline.
Duration of action after infiltration- 60-120 minutes
Maximum single dose for infiltration – 300mg
pKa- 7.9
Protein binding – 70%
Nonionized fraction at pH 7.4- 25%
Nonionized fraction at pH 7.6- 33%
Lipid solubility- 2.9, Volume of distribution- 91 liters (L)
Clearance – 0.95 L/min.
Elimination half time – 96 minutes
Effects of lignocaine.
19
BUPIVACAINE
Bupivacaine is an amide local anesthesia
Racemic preparation of R-bupivacaine and S-bupivacaine
S-bupivacaine is as potent as the racemic preparation but is less toxic
Long acting
Slow onset – 10-15 mins
17% Nonionized fraction at PH 7.4
24 % nonionized fraction at PH 7.6
Volume of distribution- 73 liters
Clearance – 0.47 L/min
Elimination half life time—210 minutes
Appropriate for procedures that last 2-2.5 hours
Available hyperbaric forms include concentrations of 0.5% and
0.75%, with dextrose 8.25%.
20
Isobaric formulations are available in concentrations of 0.5% and
0.75%.
When using isobaric solutions, the total mg dose is more important
than the total volume of medication administered.
Dose for lower limbs- 4-10mg
Dose for lower abdomen- 12-14 mg
Dose for upper abdomen- 12-18 mg
Addition of epinephrine to bupivacaine as addictive increases
duration by 50%
Addition of epinephrine increases the duration more in lumbosacral
than thoracic segments.
Metabolised by aromatic hydroxylation, N-dealkylation, amide
hydrolysis and conjugation.
N-dealkylated metabolite – N-desbutylbupivacaine is measured in
blood or urine after spinal or epidural anaesthesia
Alpha 1 acid glycoprotein is most important plasma protein binding
site.
Accidental injection of bupivacaine result in precipitous
hypotension, AV heart block, cardiac dysarrythmias.
21
After injection the protein binding sites are quickly saturated and
leaves unbound form more to diffuse into conducting system.
Premature ventricular contractions, widening of QRS complex and
ventricular tachycardia are common cardiac dysarrythmias.
Pregnancy may increase the sensitivity to cardiotoxic effects to
bupivacaine.
It intensifies and depresses electrical conduction causing reentrant
type ventricular dysarrythmias.
The addition of intrathecal fentanyl 5 mcg provides a bupivacaine
dose sparing effect similar to 15 or 20 mcg of IV fentanyl.
22
ULTRASONOGRAM
Ultrasound allows noninvasive visualization of tissue structures.
Ultrasound sound guided nerve block have become very popular and it is
essential in regional anaesthesia. In 1880, French physicists Pierre Curie
and Paul-Jacques Curie, discovered the piezoelectric effect, which can
generate and receive mechanical vibrations with high frequency. In 1978
P.La Grange and his colleagues published a case series report of ultrasound
application for peripheral nerve block. In 61 patients they performed
Supraclavicular brachial plexus block for which they used doppler
transducer to locate the subclavian artery. In 1989 Ting and
Sivagnarathnam used B mode ultrasound and demonstrated anatomy of
axilla and axillary brachial plexus block drug spread.
Ultrasound is high-frequency sound and refers to mechanical
vibrations above 20 kHz. Ultrasound frequencies commonly used for
medical diagnosis are between 2 and 15 MHz
The piezoelectric effect is an effect exhibited by the generation of an
electric charge in response to mechanical force applied on certain
materials. Mechanical deformation can be produced when an electric
field is applied to such material, also called the piezoelectric effect.
23
Quartz crystals, ceramic materials and Lead zirconate titanate are
materials that exhibit piezoelectric effect. Lead free piezoelectric
materials are under development.
PIEZOELECTRIC EFFECT
While passing through the tissue’s ultrasound wave comes across
various interactions like reflection, scattering and absorption.
Where there is a boundary between different media part of ultrasound
is reflected and the rest is transmitted. The reflection intensity is solely
dependent on the angle which means the transducer should be placed
perpendicular to the target nerve for clear visualization.
The coupling medium is necessary to displace the air from the
transducer and air interface. Gels and oils are used for this purpose they
act as lubricants providing a smooth surface scanning.
Scattering is redirection of ultrasound waves by rough surface or
heterogeneous media.
24
B MODE:
The primary mode used in regional anesthesia. It provides cross
sectional image for the area of interest. In this, there is simultaneous
scanning from a linear array of 100-300 piezoelectric crystals. The
amplitude of the echo is converted into dots of different brightness in B
scan. The echo strength is indicated by the gray scale intensity and real
distance in tissues is represented by horizontal and vertical distances.
B MODE TRANSDUCER
DOPPLER MODE- to detect the presence and nature of blood vessels.
In regional anaesthesia two types of transducers are used- Linear and
curvilinear transducers.
25
Linear Curvilinear
Rectangular Curvilinear in shape
Beam is rectangular, and the near-
field resolution
Convex beam and in-depth
examinations
2 to 16 MHz 2 to 7 MHz
Linear and Curvilinear Probe
26
The peripheral nerves are in close vicinity to the vessels or between
the muscle layers in general. The echo texture can be hyperechoic,
hypoechoic or honeycomb pattern. To facilitate adequate nerve imaging,
proper selection of sonographic modes, functional keys adjustment, needle
visualization and image artifact interpretation are the certain steps. For
peripheral nerve visualization three imaging modes are commonly used-
conventional imaging, compound imaging and tissue harmonic imaging
(THI).
For achieving an optimal image while performing peripheral nerve
imaging five functional keys on an ultrasound machine play vital role
1) Depth 2) Frequency 3) Focusing 4) Gain 5) Doppler
COMPOUND AND CONVENTIONAL IMAGING
27
With the relevance to needle -transducer relationship, two needle
insertion techniques are being used commonly.
In-plane technique: Needle is placed in the plane of ultrasound beam.
Hence the needle shaft and tip can be observed in the longitudinal view
when it is advanced towards the target structure. One should stop
advancing the needle when the needle visualization fails. Tilting or rotating
the transducer can help with visualization.
Out of plane technique: The needle is inserted perpendicular to the
transducer. The shaft of the needle is seen in the cross-sectional plane and
as a bright dot.
IN-PLANE AND OUT OF PLANE TECHNIQUE
28
OPERATIONAL SETUP
FIELD DEPTH
(CMS)
FREQUENCY
(MHZ)
PERIPHERAL BLOCKADES
< 2 12-15 Wrist, ankle block
2-3 10-12 Interscalene and axillary
3-4 10-12 Femoral, Supraclavicular and TAP
4-7 5-10 Infraclavicular, Popliteal and sub gluteal
sciatic nerve block
7-10 5-10 Pudendal, gluteal sciatic and lumbar
plexus block
>10 3-5 Anterior approach to sciatic nerve
IMAGING DEPTH AND FREQUENCY FOR COMMON
PERIPHERAL NERVE BLOCKS
29
FASCIA ILIACA COMPARTMENT BLOCK
INDICATIONS
To reduce the requirement for systemic analgesics such as opioids
and NSAID’s and avoid their side effects.
Pre-op analgesia for patients with neck of femur or femoral shaft
fractures.
Analgesia for the application of POP in children with femoral
fractures
Analgesia for AK amputation
Analgesia for knee surgeries
CONTRA-INDICATIONS
Patient refusal
Allergy or previous anaphylactic reaction to local anaesthetic.
Inflammation or infection over the site of injection.
Previous femoral-bypass surgery, or near a graft site.
Abnormal coagulation studies.
Complications:
Intravascular injection
Block failure
Nerve damage
Infection
30
Ultrasound Technique
The ultrasound-guided technique is essentially the same.
Monitoring of the needle placement and local anesthetic delivery
assures deposition of the local anesthetic into the correct plane.
• Transducer position: transverse, close to the femoral crease and lateral to
the femoral artery.
• Goal: medial–lateral spread of local anesthetic underneath the fascia
iliaca
• Local anesthetic: 20ml of lignocaine 2% with adrenaline 5mcg/ml
Identifying the femoral artery at the level of the inguinal crease. If it is
not immediately visible, sliding the transducer medially and laterally
will eventually bring the vessel into view.
Immediately lateral and deep to the femoral artery and vein is a large
hypoechoic structure, the iliopsoas muscle It is covered by a
31
hyperechoic fascia, which can be seen separating the muscle from the
subcutaneous tissue superficial to it.
The hyperechoic femoral nerve should be seen wedged between the
iliopsoas muscle and the fascia iliaca, lateral to the femoral artery.
The fascia lata (superficial in the subcutaneous layer) is more superficial
and may have more than one layer.
Moving the transducer laterally several centimeters brings into view the
sartorius muscle covered by its own fascia as well as the fascia iliaca.
Further lateral movement of the transducer reveals the anterior superior
iliac spine.
Equipments required:
The equipment needed for a fascia iliaca block includes the following:
Ultrasound machine with linear transducer (6–14 MHz), sterile
sleeve, and gel
Standard nerve block tray.
20-mL syringes containing local anesthetic
80- to 100-mm, 22-gauge needle
32
PATIENT POSITIONING AND LANDMARKS
This block is typically performed with the patient in the supine position,
with the bed or table flattened to maximize access to the inguinal area.
Although palpation of a femoral pulse is a useful landmark, it is not
required because the artery is quickly visualized by placement of the
transducer transversely on the inguinal crease, followed by slow
movement laterally or medially.
Tilting the probe while pressing helps to identify the hyperchoic fascia
iliaca superficial to the hypoechoic iliopsoas muscle.
Medially, the Femoral nerve is visualized deep to the fascia and lateral
to the artery Laterally, the sartorious muscle is identified by its typical
triangular shape when compressed by the transducer.
33
34
TECHNIQUE
With the patient in the proper position, the skin is disinfected and
the transducer positioned to identify the femoral artery and the iliopsoas
muscle and fascia iliaca. The transducer is moved laterally until the
sartorius muscle is identified. After a skin wheal is made, the needle is
inserted in plane.
As the needle passes through fascia iliaca, the fascia is first seen
indented by the needle. As the needle eventually pierces the fascia, a “pop”
may be felt, and the fascia may be seen to “snap” back on the US image.
After negative aspiration, 1–2 mL of local anesthetic is injected to confirm
the proper injection plane between the fascia and the iliopsoas muscle .
If local anesthetic spread occurs above the fascia or within
thesubstance of the muscle itself, additional needle repositions
andinjections may be necessary. A proper injection will result in
theseparation of the fascia iliaca by the local anesthetic in themedial–lateral
direction from the point of injection as described.
Releasing the pressure of the transducer may reduce the resistance
to injection and improve the distribution of local anesthetic. In an adult
patient, 20 mL of local anesthetic is usually required for successful
blockade. In children, 0.7 mL/kg is commonly used. The success of the
block is best predicted by documenting the spread of local anesthetic
35
toward the femoral nerve medially and underneath the sartorius muscle
laterally.
In obese patients, an out-of-plane technique may be favored. An
alternative suprainguinal technique may result in a more proximal spread
and possibly more efficacious analgesia after hip surgery.
36
FEMORAL NERVE BLOCK
Advantages:
Suitable for post op analgesia
When unilateral block is desired.
Disadvantages:
Unpredictable success rate
Longer onset time
Increased likelihood of systemic toxicity
INDICATIONS:
Analgesia for positioning of patient in femur fracture
Outpatient procedures
Post op pain care in fracture femur neck, shaft of femur fracture,
patellar fractures
Early mobilization after THR/TKR
CRPS type 1 and 2
Post amputation pain
Polyneuropathy
Arthritis
37
CONTRAINDICATIONS:
Infection or inflammation at the site of injection
Hematoma at the site
Abnormal coagulation studies
Hemorrhagic diathesis
Patients with femoral bypass
Local nerve injury
POSITIONING:
Supine
LANDMARK TECHNIQUE
The femoral artery is palpated 1 to 2 cms distal to inguinal ligament,
held between index and middle finger
Injection point lies 1-1.5 cm laterally
Then give 20ml of Inj.Lignocaine 2% with intermittent aspiration
38
CONTRAINDICATIONS:
Infection or inflammation at the site of injection
Hematoma at the site
Abnormal coagulation studies
Hemorrhagic diathesis
Patients with femoral bypass
Local nerve injury
ULTRASOUND TECHNIQUE
• Transducer position: transverse, femoral crease
• Goal: local anesthetic spread adjacent to the femoral nerve
• Local anesthetic: 10–15 mL
39
ULTRASOUND ANATOMY
Orientation begins with the identification of the femoral artery at the
level of the femoral crease. Commonly, the femoral artery and the deep
artery of the thigh are both seen. In this case, the transducer should be
moved proximal until only the femoral artery is seen .The femoral nerve is
lateral to the vessel and covered by the fascia iliaca; it is typically
hyperechoic and roughly triangular or oval in shape. Femoral nerve
typically is visualized at a depth of 2-4cm.
DISTRIBUTION OF ANESTHESIA
Femoral nerve block results in anesthesia of the anterior and medial
thigh down to and including the knee, as well as a variable strip of skin on
the medial leg and foot. It also innervates the hip, knee, and ankle joints.
EQUIPMENT
The equipment recommended for a femoral nerve block includes the
following:
• Ultrasound machine with linear transducer (8–18 MHz), sterile sleeve,
and gel
• Standard nerve block tray
• One 20-mL syringe containing local anesthetic
• A 50- to 100-mm, 22-gauge, needle
• Sterile gloves
40
PATIENT POSITIONING AND LANDMARKS
This block typically is performed with the patient in the supine position,
with the bed or table flattened to maximize operator access to the inguinal
area. The transducer is placed transversely on the femoral crease, over the
pulse of the femoral artery, and moved slowly in a lateral-to-medial
direction to identify the artery.
TECHNIQUE
With the patient in the supine position, the skin over the femoral
crease is disinfected and the transducer is positioned to identify the femoral
artery and nerve. If the nerve is not immediately apparent lateral to the
artery, tilting the transducer proximally or distally often helps to image and
highlight the nerve from the iliacus muscle and the more superficial
adipose tissue. In doing so, an effort should be made to identify the iliacus
muscle and its fascia, as well as the fascia lata, because injection
underneath a wrong fascial sheath may result in block failure.
Once the femoral nerve is identified, a skin wheal of local anesthetic
is made 1 cm away from the lateral edge of the transducer. The needle is
inserted in plane in a lateral-to medial orientation and advanced toward the
femoral nerve.
In addition, a needle passage through the fascia iliaca is often felt.
Once the needle tip is adjacent (either above, below, or lateral) to the nerve
41
.and after careful aspiration, 1–2 mL of local anesthetic is injected to
confirm proper needle placement .Proper injection will push the femoral
nerve away from the injection.
Additional needle repositions and injections are done only when
necessary. In an adult patient,20ml of local anesthetic is adequate for a
successful block.
42
SPINAL ANAESTHESIA
Spinal anesthesia involves use of small amounts of local anesthetic
injected into subarachnoid space to produce a reversible loss of sensation
and motor function. The anesthesia provider places the needle below L2 in
the adult patient to avoid trauma to the spinal cord. Spinal anesthesia
provides excellent operating conditions for:
Advantages of Spinal Anesthesia
Easy to perform
Reliable
Provides excellent operating conditions for the surgeon
Less costly than general anesthesia
Normal gastrointestinal function returns faster with spinal anesthesia
compared to general anesthesia
Patient maintains a patent airway
A decrease in pulmonary complications compared to general
anesthesia
43
Decreased incidence of deep vein thrombosis and pulmonary emboli
formation compared to general anesthesia
Disadvantages of Spinal Anesthesia
Risk of failure even in skilled hands. Always be prepared to induce
general anesthesia.
Normal alteration in the patient’s hemodynamics. It is essential to
place the spinal block in the operating room, while monitoring the
patient’s ECG, blood pressure, and pulse oximetry. Resuscitation
medications should be available.
The operation could outlast the spinal anesthetic. Alternative plans
(i.e. general anesthesia) should be prepared in advance
Mechanism of Action
Local anesthetics administered in subarachnoid space block sensory,
autonomic, and motor impulses as the anterior and posterior nerve roots
pass through the CSF. The site of action includes spinal nerve roots and
dorsal root ganglion
Technique
The technique of administering spinal anesthesia can be described :
preparation, position, projection, and puncture
44
Preparation
Discuss with the patient options for anesthesia. Explain risk and
benefits. Inform the patient about the following: despite sedation
patient may remember portions of the surgical procedure but
shouldn’t feel discomfort, the patient may feel pressure sensations
but no pain, the patient will not be able to move their legs
Choose an appropriate local anesthetic..
Choose the appropriate spinal needle. Spinal needles are available in
a variety of sizes (from 16-30 gauge), lengths, bevel types, and tip
designs. A 25-27 gauge needle is commonly used in patients that are
less than 50 years of age. A smaller needle is used in the younger
patient to decrease post dural puncture headache. Needles are cutting
or blunt tiped. The Quincke needle is a cutting needle, with the
opening at end of the needle
Blunt tipped needles (pencil point) decrease the postdural puncture
headaches compared to cutting needles. Whitacre and other pencil point
needles, have a rounded tip with a side port. Sprotte needles have a long
opening, allowing excellent CSF flow.
Positioning
There are 3 positions used for the administration of spinal
anesthesia: lateral decubitus, sitting, and prone
45
Lateral Decubitus
Allows the anesthesia provider to administer more sedation- less
dependence on an assistant for positioning. (Never over sedate a
patient).
The patient is positioned with their back parallel with the side of the
operation table. Thighs are flexed up, and the neck is flexed forward
(fetal position).
Patient should be positioned to take advantage of the baricity of the
local anesthetic
Sitting
Used for anesthesia of the lumbar and sacral levels.
Identify anatomical landmarks. This may be a challenge in the obese
or those with abnormal anatomical curvatures of the spine. Place the
patient feet on a stool, have the patient sit up straight, head flexed,
arms hugging a pillow. Make sure the patient does not simply lean
forward.
46
For a lower lumbar/sacral block (i.e. saddle block), leave the patient
sitting for 15 minutes before assuming a supine position
Prone
The prone position is used when the patient will be in this position
for the surgical procedure like rectal, perineal and lumbar surgeries.
Hypobaric local anesthetics are usually administered Patient
positions self, lumbar lordosis should be minimized, paramedian
approach is often used.
Projection and Puncture
There are two approaches to access the subarachnoid space:
paramedian and midline approach.
47
Midline Approach
The midline approach affords the practitioner two advantages.
Anatomic projection is only in 2 planes, making visualization of the
intended trajectory and anatomical structures more apparent. The midline
provides a relatively avascular plane.
“Tuffier’s” line is a line drawn across the iliac crest that crosses the
body of L4 or L4-L5 interspace. This is a helpful landmark for the
placement of spinal or epidural anesthetics.
Paramedian Approach
The advantage of the paramedian approach is a larger target. By
placing the needle laterally, the anatomical limitation of the spinous
process is avoided. The most common error when attempting this
48
technique is being too far from the midline, which makes encountering the
vertebral lamina more likely.
Palpate the vertebral process and identify the caudad tip. Move 1 cm
down and 1 cm laterally.
49
REVIEW OF LITERATURE
1. The study titled “Ultrasound Guided Femoral Nerve Block to Provide
Analgesia for Positioning Patients with Femur Fracture Before
Subarachnoid Block: Comparison with Intravenous Fentanyl”
It is randomized trial done on Forty patients undergoing surgery for
femur fracture were randomized to either femoral nerve block (FNB) or
intravenous fentanyl (IVF) group. Group FNB (n=20) received 20 ml of
2% lignocaine around femoral nerve under ultrasound guidance. IVF group
(n=20) received 2 mc/kg of fentanyl intravenously. Pain score on effected
limb was assessed after five minutes. If VAS was ≤ 4, the patient was
positioned in sitting for subarachnoid block. On failure to achieve this with
the above treatment, intravenous fentanyl 0.5 mc/kg was administered and
repeated as necessary before positioning.
VAS during positioning was documented and compared between the
two groups. Similarly, secondary outcomes of the intervention: quality of
patient position, rescue analgesia and duration of the procedure were also
compared. Data were subjected to Mann Whitney U-test and chi-square
test. Level of significance was set at 0.05.Result: FNB group had
significantly less VAS scores (median) than IVF group :2 vs 3; p=0.037)
during positioning for spinal anaesthesia. Procedure time (median) for
spinal anaesthesia was also significantly less in FNB than in IVA group
(10 vs 12 min; p=0.033) Ultrasound guided femoral nerve block was
50
more effective than intravenous fentanyl for reducing pain in patients
with proximal femur fracture before spinal anaesthesia.
2. The study titled “Analgesia before a spinal block for femoral neck
fracture: fascia iliaca compartment block”
In this study the 40 patients were randomly assigned to one of two
groups, namely, the FIC group (fascia iliaca compartment block, n520) and
the IVA group (intravenous analgesiawith alfentanil, n520). Group IVA
patients received a bolus dose of i.v. alfentanil 10mg/kg, followed by a
continuous infusion of alfentanil 0.25mg/kg/min starting 2 min before the
spinal block, and group FIC patients received a FIC block with 30 ml of
ropivacaine 3.75 mg/ml (112.5 mg) 20 min before the spinal block. Visual
analogue pain scale (VAS) scores,time to achieve spinal anaesthesia,
quality of patient positioning, and patient acceptance were compared.
Results: VAS scores during positioning (mean and range) were lower in
the FIC group than in the IVA group [2.0 (1–4) vs. 3.5 (2–6), P50.001],
and the mean (_ SD) time to achieve spinal anaesthesia was shorter in the
FIC group (6.9 _ 2.7min vs. 10.8 _ 5.6min; P50.009). Patient acceptance
(yes/no) was also better in the FIC group (19/1) than in the IVA group
(12/8)(P50.008).they concluded that an FIC block is more efficacious
than i.v.alfentanil in terms of facilitating the lateral position for spinal
anaesthesia in elderly patients undergoing surgery for femoral neck
fractures.
51
3. The study titled “Analgesia before Performing Subarachnoid
Block in the Sitting Position in Patients with Proximal Femoral
Fracture: A Comparison between Fascia Iliaca Block and Femoral
Nerve Block”
In this study, Group FICB patients (n=15) received fascia iliaca block
with 30 ml of 1.5% lignocaine with adrenaline and group FNB patients
(n=15) received femoral nerve block with 15 ml of 1.5% lignocaine with
adrenaline. After the study blocks, patients were kept on supine position
for at least 20 minutes before shifting them to the operation theatre. Pain
was assessed by using visual analog scale values before the block and
during the position for subarachnoid block. Time to perform subarachnoid
block, quality of positioning and acceptance was recorded.
Visual analog scale values during positioning for SAB were lower
in FIB group than in FNB (1.0±1.1 versus 2.1±0.8; P<0.05). Time to
perform SAB was shorter in FIB than in FNB (109.6±28.2 seconds vers us
134.8±31.9 seconds; P<0.05). Quality of patient positioning for SAB was
comparable between the groups. Patient acceptance was less in group FNB
(P<0.05).
They concluded that Fascia iliaca compartment block provides
better analgesia than femoral nerve block in terms of facilitating
optimal positioning for subarachnoid block in patients undergoing
proximal femoral fracture fixation procedure
52
4. The study titled “ULTRASOUND-GUIDED CONTINUOUS
FEMORAL NERVE BLOCK VS CONTINUOUS FASCIA
ILIACA COMPARTMENT BLOCK FOR HIP REPLACEMENT IN
THE ELDERLY”: A RANDOMIZED CONTROLLED CLINICAL
TRIAL.
Department of Anesthesiology, Tongji Hospital of Tongji
University, Shanghai, China.
In this prospective, randomized controlled clinical investigation, 60
elderly patients undergoing hip replacement were randomly assigned to
receive either continuous femoral nerve block or
continuous fascia iliaca compartment block. After ultrasound-guided
nerve block, all patients received spinal anesthesia for surgery and
postoperative analgesia through an indwelling cannula.
There was a significant difference between the 2 groups in the mean
visual analog scale scores (at rest) at 6 hours after surgery: 1.0 ± 1.3 in
the femoral nerve block group vs 0.5 ± 0.8 in
the fascia iliaca compartment block group (P < 0.05). The femoral
nerve block group had better postoperative analgesia on the medial aspect
of the thigh, whereas the fascia iliaca compartment block group had better
analgesia on the lateral aspect of the thigh. There were no other significant
differences between the groups.they concluded that on Both ultrasound-
guided continuous femoral nerve block and fascia iliaca compartment
53
block with the novel cannula-over-needle provide effective anesthesia and
postoperative analgesia for elderly hip replacement patients.
5. The study titled A Randomized Study to Compare the Analgesic
Efficacy of Ultrasound-Guided Block of Fascia Iliaca Compartment
or Femoral Nerve After Patella Fracture Surgery.
Department of Anesthesia, Jiangyin Hospital, Medical College of
Southeast University, No. 163, Shoushan Rd, Jiangyin, 214400, China.
The aim of this study was to compare the analgesic efficacy of the
ultrasound-guided block of femoral nerve or fascia iliaca compartment in
patients who underwent patella fracture surgery. Fifty patients were
blinded and randomized into groups treated with continuous
fascia iliaca compartment block (CFICB) (n = 25) or continuous femoral
nerve block (CFNB) (n = 25) after patella fracture surgery. Analgesic
effects of the two methods were assessed and compared. Patients from the
two groups showed no significant difference in visible analog scales at rest
and during movement, fentanyl consumption, nausea, and vomiting. The
time of catheter insertion was significantly shorter in carrying out CFICB
compared to that in performing CFNB (8.3 ± 1.4 vs 14.5 ± 3.0 min). Three
of the 25 patients in CFNB group experienced dysesthesia of anterior of
the thigh, a complication which was not observed in CFICB-treated
patients. CFICB and CFNB were equally effective in relieving pain after
54
the patella fracture surgery. However, compared to CFNB, CFICB was
found to be safer and easier to perform.
6. Iliac Fascia Compartment Block and Analgesic Consumption in
Patients Operated on for Hip Fracture.
patients undergoing surgical treatment of proximal femur fractures was
performed. Group 1 (n=35)consisted of patients who were treated with
pharmacologic analgesia only (systemic analgesics) and Group 2 (n=43)
involved patients who received a preoperative fascia iliaca compartment
block (FICB) and pharmacologic analgesia. FICB was per-formed under
ultrasound guidance, and systemic analgesics were administered according
to a standardized pro-to-col. Demographics, anesthesia and operation data
as well as the dosage of analgesics used on postoperative day 0 were
collected for the study.Patients with antecedent iliac fascia blockade
required fewer analgesic interventions (3 vs. 11, p <0.0001) and showed
significantly less need for analgesics than non-block patients. No
complications were observed after performing FICB. They concluded that
The iliac fascia compartment block produces effective postoperative
analgesia and reduces postoperative opioid consumption.
7. A comparison of two approaches to ultrasound-guided fascia iliaca
compartment block for analgesia after total hip arthroplasty.
55
Before induction of general anethesia, ultrasound-guided FICB were
administered. According to probe parallel to the inguinal ligament or
perpendicular to the inguinal ligament, patients were randomly divided into
the Parallel group and the Perpendicular group. Both groups was
administered an equal volume mixture of 1% ropivacaine and 1%
lidocaine, 30 ml in total. All patients received sufentanil postoperative
intravenous analgesia after surgery. Time to ultrasonic imaging, time to
perform the block and total blocking time were recorded. Loss of sensation
in the distribution areas of the femoral nerve and
lateral femoral cutaneous nerve within 30 mins were recorded. Patients
were interviewed at 4, 8, 12, 24, 36, 48 h after block for pain intensity, time
of first using PCA, sufentanil consumption and loss of skin sensation due
to the block. The occurrence of adverse events (nausea, vomiting,
respiratory inhibition, pruritus or urinary retention) was also recorded.they
concluded that Comparing the two approaches to ultrasound-guided FICB,
ultrasonic probe perpendicular to the inguinal ligament may offer better
blocking effect of lateral cutaneous nerve and reduce postoperative
sufentanil consumption, and might be more suitable for analgesic after
THA.
8 .The study titled “ Fascia iliaca block vs intravenous fentanyl as
ananalgesic technique before positioning for spinal anesthesia in
patients undergoing surgery for femur fractures”
56
Department of Anesthesiology, MS Ramaiah Medical College and
Hospitals, Bangalore, India
It is a randomized controlled trial done on Sixty patients aged 25 to
75 years, with ASA statusI to III, undergoing surgery for femur
fracturewere chosen for the study and randomized into 2 groups. Patients
in groupFICB received the block with 30 mL of 0.375% ropivacaine 15
minutes before the subarachnoid block. Patients in group IVF received
intravenous fentanyl at 0.5 μg/kg body weight repeated up to a maximum
of 3 doses. Spinal was administered using 12 to 15mgof 0.5%hyperbaric
bupivacaine with glucose 80mg/mL in patients of both groups.
Measurements: Pre procedural and post procedural parameters such as
visual analog scale (VAS) scores, sitting angle, quality of positioning, and
time to perform the spinal were recorded. Patients were also assessed in
the first 24 hours for analgesic requests .
They concluded that Preprocedural VAS scores were similar in both
groups. The “VAS after” was 24.72 ± 15.70 mm in group FICB vs 61.22 ±
18.18 mm in group IVF (P = .01). The drop in VAS scores was
significantly more in the FICB group. Sitting angle improved
significantly in the FICB group.(56.17° ± 16.54° vs 21.38° ± 23.90°; P
= .01). Patients in group FICB also needed less time for spinal and had
better quality of positioning. Postoperative analgesic requirement was
lesser in group FICB.
57
AIM AND OBJECTIVES
Compare the feasibility and effectiveness of fascia iliaca block and
femoral nerve block in reducing pain associated with positioning for
subarachnoid block in patients undergoing proximal femour fixation
procedures.
PRIMARY OUTCOME
VAS score before and VAS score at positioning for SAB.
SECONDARY OUTCOME
Time to performance of Spinal block
Quality of positioning during spinal Anaesthesia
No of attempts
Hemodynamic variability
Failure to Perform Spinal Anaesthesia
58
MATERIALS AND METHODS
After obtaining informed and written consent from 60 ASA 1, 2 and
3 patients, who were scheduled for orthopedic surgeries (lower limb) in
Government Rajaji Hospital, Madurai were participated in this study.
Hospital ethical committee approval was obtained.
60 patients were randomized into 2 groups,
Group 1- FICB
Group 2- FEMORAL NERVE BLOCK
INCLUSION CRITERIA
ASA 1,2 and 3
Age-18 to 65 years
Both sexes
Proximal femour fixation surgery
EXCLUSION CRITERIA
ASA 4
Age <18 and >65
Allergic to local anaesthetics
Hepatic or renal failure
Coagulation abnormalities
Infection/Inflammation at the site of injection .
59
ANAESTHETIC TECHNIQUE
All the patients were premedicated with Inj.Midazolam 50mcg/kg
IM half an hour before surgery.
Preoperatively patient’s PR, BP, Spo2,RR and Visual analog scale
(VAS) for pain at Rest and movement were noted.
The patients were assessed for pain using a 10-point VAS before
performing block.
GROUP FICB:
o Receive usg guided fascia iliaca compartment block .
o They were given 1.5% inj.lignocaine 20 ml with inj.adrenaline
5mic/ml.
60
GROUP FNB:
o receive usg guided femoral nerve block.
o They were given 1.5% inj.lignocaine 20 ml with inj.adrenaline
5mic/ml
Techniques of block were described earlier in this chapter .
After performing the blocks the patients were kept in supine position
for at least 20 min .
The patients were made to sit with the help of operation theatre
assistants while the skeletal traction was maintained.
VAS was enquired and noted.
Once the patient was in sitting position SAB was administered and laid
down back to supine position.
Time required to perform SAB (as defined as time from insertion of
the spinal needle to complete deposit of drug in the subarachnoid space)
was noted.
quality of patient positioning
Positioning was subjectively rated as good or satisfacfactory depending
on the ease of positioning for SAB.
No of attempts
No of attempts for performance of spinal anaesthesia were calculated.
Hemodyamic Variability
Hemodyamic changes were noted
61
STATISTICAL ANALYSIS
Data were analysed using the SPSS 20 software.
The clinical profile of patients was analysed using chi-square test
for categorical data and Unpaired t-test for continuous data
p value less than 0.05 was considered statistically significant.
62
OBSERVATION
Age distribution
Age in years Group FNB Group FICB
< 40 3 2
41 - 50 9 7
51 - 60 12 14
> 60 6 7
Total 30 30
Mean 53.07 54.6
SD 8.65 8.11
t' value 0.708
p' value 0.482 Not significant
INFERENCE
Age of the patients were comparable between two groups.
3
9
12
6
2
7
14
7
0
2
4
6
8
10
12
14
16
< 40 41 - 50 51 - 60 > 60
PA
TIE
NT
S
AGE IN YEARS
AGE DISTRIBUTION -COMPARISON
Group FNB Group FICB
63
Gender distribution
INFERENCE
Gender data were comparable between the groups.
0
5
10
15
20
Male Female
18
12
18
12
PA
TIE
NT
S
GENDER
GENDER COMPARISON
Group FNB Group FICB
Gender Group FNB Group FICB
Male 18 18
Female 12 12
Total 30 30
Chi square 0.069
p value 0.792 Not Significant
64
Weight distribution
Weight in kgs Group FNB Group FICB
< 50 2 5
51 - 56 17 8
61 - 70 10 16
> 70 1 1
Total 30 30
Mean 59.2 61.87
SD 7.14 8.44
t' value 1.32
p' value 0.192 Not significant
INFERENCE
Weight of the patients were comparable between two groups.
0
5
10
15
20
< 50 51 - 56 61 - 70 > 70
2
17
10
1
5
8
16
1
PA
TIE
NT
S
Wt in Kgs
WEIGHT COMPARISON
Group FNB Group FICB
65
Vas score at block
INFERENCE
VAS score at block were comparable between two groups.
0
10
20
30
2 3 4 5
1
1412
30
23
6
1PA
TIE
NT
S
VAS SCORE
VAS SCORE AT BLOCK
Group FNB Group FICB
VAS at Block Group FNB Group FICB
Score 2 1 0
3 14 23
4 12 6
S 5 3 1
Total 30 30
Mean 3.57 3.27
SD 0.73 0.52
t' value 1.836
p' value 0.072 Not significant
66
VAS AT POSITIONING FOR SAB
vas at positioning for
SAB Group FNB Group FICB
Score 0 0 1
1 1 20
2 16 9
S 3 13 0
Total 30 30
Mean 2.4 1.27
SD 0.57 0.52
t' value 8.09
p' value < 0.001 Significant
INFERENCE
VAS score at positioning for sab is better in FASCIA ILLIACA
COMPARTMENT BLOCK than FEMORAL NERVE BLOCK.
0
5
10
15
20
0 1 2 3
0 1
16
13
1
20
9
0
PA
TIE
NT
S
VAS SCORE
VAS AT POSITIONING FOR SAB
Group FNB Group FICB
67
0
1
2
3
Group FNB Group FICB
2.4
1.27
PA
TIE
NT
S
VAS SCORE
Mean VAS SCORE AT POSITIONING FOR SAB
Group FNB Group FICB
68
Time to performing spinal anaesthesia
Time to perform SAB Group FNB Group FICB
< 120 9 25
121 - 140 13 5
> 140 8 0
Total 30 30
Mean 133 107.2
SD 15.45 11.08
t' value 7.431
p' value < 0.001 Significant
INFERENCE
Time required for performing the SAB is much lower in FICB than
FNB group Better pain relief and, therefore, better positioning with
the FICB group.
0
50
100
150
Group FNB Group FICB
133107.2
PA
TIE
NT
S
TIME in Sec
Mean TIME TO PERFORM SAB
Group FNB Group FICB
69
Quality of positioning
Quality Group FNB Group FICB
Good 21 28
Unsatisfactory 9 2
Total 30 30
Chi square 4.007
p value 0.045 Significant
INFERENCE
Good analgesia and paralysis of some muscles (eg. quadriceps)
following FICB are the likely reasons for more comfortable positioning in
the group.
0
10
20
30
Good Unsatisfactory
21
9
28
2PA
TIE
NT
S
SATISFACTION SCORE
QUALITY COMPARISON
Group FNB Group FICB
70
NO OF ATTEMPTS COMPARISON
PATIENTS
No of attempts
INFERENCE:
FICB has made spinal anaesthesia position easier compared to femoral
nerve block. 30 patients out 30 were shown successful single attempt for
spinal anaesthesia in FICB group and only 22 patients out of 30 in FNB
group.
0
5
10
15
20
25
30
group fnb gp ficb
one attempt
more than one attempts
NO OF ATTEMPTS Group FNB Group FICB
One attempt 22 30
More than one attempts 8
0
Total 30 30
P value <0.005
71
HEMODYNAMIC VARIABILITY
SYSTOLIC BLOOD PRESSURE DURING POSINING OF SPINAL
ANAESTHESIA
100
105
110
115
120
125
130
135
baseline 1min 2min 3min 4 min 5 min 6 min
Group FNB
Group FICB
72
DIASTOLIC BLOOD PRESSURE DURING POSITIONING FOR
SPINAL ANAESTHESIA
0
20
40
60
80
100
120
baseline 1min 2min 3min 4min 5min 6min
Group FNB
Group FICB
73
PULSE RATE VARIABILITY DURING POSITIONING OF
SPINAL ANAESTHESIA
0
20
40
60
80
100
120
Baseline 0 min 1 min 2 min 3 min 4 min 5 min
Group FNB
Group FICB
74
RESULTS
The two groups were similar in terms of Age, Sex, Weight and
preoperative VAS both at rest and during movement. Baseline VAS scores
at the time of block were comparable between the groups.
Mean VAS score at positioning for SAB was signifiantly lower in
group FICB than in group FNB. Performance time for SAB in group FICB
was significantly shorter than FNB.
Performer rated quality of positioning was significantly better in
group FICB than group FNB. Patients acceptance was better in group FICB
than in group FNB. Rescue analgesia was required in two patients, one
from each group.
No of attempts for performing spinal anaesthesia was significantly
lower in FICB group than FNB group. No adverse systemic toxicity of
lignocaine was noted.
No complications such as hematoma or persistent paresthesia were
observed in patients with both the techniques of blocks within following
24 hours after the operation.
75
DISCUSSION
Positioning patients for spinal anesthesia with fractured femur is
challenging because even minimal overriding of the fracture ends is
exceedingly painful.
Providing analgesia before positioning not only increases patient
comfort but also improves positioning and successful spinal block
Fascia illiaca block offers superior analgesia compared to femoral nerve
block in patients with femur fracture during positioning for spinal
anaesthesia.
Visual analog scale during positioning of spinal anaesthesia Both
techniques provided reduction in VAS during positioning but
Reduction in VAS by FICB was higher than FNB in the present study
with higher significance.
VAS score 2.4 ±0.57 in FNB group were only 1.27 ±0.57 in FICB
group The obturator and lateral cutaneous nerve of thigh are not
affected by the FNB, explaining less reduction in pain in the group
This is in agreement with the study done by Dalen et al and Capdevila
et al.
76
TIME FOR PERFORMANCE OF SAB
Time required for performing SAB with FICB was almost half a
minute less than that of FNB in the present study. Better pain relief and,
therefore, better positioning with the FICB is well reflected in the time
required for performing the SAB.
Time required for performing SAB with FNB group is 133± 15.45
sec where as in FICB it is only 107±11.08 sec. Time required for
performing SAB were comparable between two groups. This is in
agreement with the study done by time reported by Sia et al.
Quality of positioning
Good analgesia and additional involvement of obturator nerve ana
lateral cutaneous nerve of thigh following FICB are the likely reasons for
more comfortable positioning in the group.
28 patients out 30 were shown good satisfaction with positioning and only
21 patients in group FNB shown good satisfaction with positioning.
No of attempts
Due to optimal positioning for SAB all the patients in group FICB-
are able to perform spinal within one attempt, but in group FNB only in 22
patients spinal performed within one attempts, remaining patients
successful in subsequent attempts.
77
Failure to give spinal anaesthesia
There was no failure in performing spinal anaesthesia in both
groups.
Complication
There was no failed block or patchy block noted.
There was no complications like giddiness,sweating while performing
spinal anaesthesia.
The results obtained by previous study regarding VAS score during
positioning for spinal anaesthesia ,time to perform spinal anaesthesia , and
patient satisfaction, no of attempts were similar to our study
78
CONCLUSION
Study demonstrate that fascia iliaca compartment block provides
better analgesia than femoral nerve block in terms of facilitating
optimal positioning for subarachnoid block in patients undergoing
proximal femoral fracture fixation procedure.
Being done under ultrasound guidance the risk of complications are
minimal.
79
BIBILOGRAPHY
1. 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
(4): 309-14.
2. Capdevila X, Biboulet P,Bouregba M, Barthelet Y, Rubenovitch J,
d’Athis F. Comparison of three-in-one and fascia iliaca compartment
blocks in adults: clinical and radiographic analysis. Anesth Analg 1998;
86 (5): 1039-44
3. Dalens B, Vanneuville G, Tanguy A. Comparison of fascia iliaca
compartment block with 3-in-1block in children. Anesth Analg 1989;
69 (6): 705-13.
4. Monzon DG, Iserson KV, Vazquez JA. Single fascia iliaca
compartment block for post-hip fracture pain relief. J Emerg Med.
2007; 32 (3): 257-62.
5. Beaudoin FL, Nagdev A, Merchant R, Becker B. Ultrasound guided
femoral nerve blocks in elderly patients with hip fracture. American
journal of emergency medicine 2010; 28, 76-81.
80
6. Candal-Couto JJ, Mc Vie JL, Haslam N, Innes AR, Rushmer J. Pre-
operative analgesia for patients with femoral neck fractures using a
modified fascia iliaca block technique. Injury. 2005; 36 (4): 505-10.
7. Haines L, Dickman E, Ayvazyan S, Wu S, Rosenblum D, Likourezos
A. Ultrasound guided fascia iliaca compartment block for hip fractures
in the emergency department. J Emerg Med. 2012; 43(4): 692-7.
8. Sia S, Pelusio F, Barbagli R, Rivituso C. Analgesia before performing
a spinal block in the sitting position in patients with femoral shaft
fracture: A comparison between femoral nerve block and intravenous
fentanyl. Anesth Analg 2004;99:1221-4.
9. . Yun MJ, Kim YH, Han MK, Kim JH, Hwang JW, Do SH. Analgesia
before a spinal block for femoral neck fracture: fascia iliaca
compartment block. Acta Anaesthesiol Scand. 2009;53(10):1282-7
81
PROFORMA
NAME : I.P.NO: ASA:
AGE & SEX: WEIGHT :
DATE& TIME OF ADMISSION:
DATE& TIME OF DISCHARGE:
DIAGNOSIS:
PROCEDURE:
HISTORY: allergy to drugs ,uncontrolled hypertension, diabetes
mellitus, pulmonary pathology - asthma , COPD, h/o intake of beta
blockers, calcium channel blockers, long time opioid/NSAID intake, H/o
any other cardiac or respiratory medications
CLINICAL EXAMINATION: PR,BP, SPO2, RS, CVS.
BASIC INVESTIGATIONS:
Haemoglobin,
Random Blood Glucose
Renal Parameters & Serum Electrolytes,
Liver Parameters
ANAESTHETIC TECHNIQUE: Cases posted for proximal femour
fracture fixation surgery under subarachnoid block
They were randomly divided into two groups using sealed envelope
techniques:
82
GROUP FICB: group FICB to receive fascia iliaca compartment block.
GROUP FNB: group FNB to receive femoral nerve block.
Complications IF Any:
MONITORING OF VITALS:
PARAMETERS TO BE MONITORED:
1. VAS during block,
2. VAS at positioning for spinal anaesthesia,
3. Time to perform subarachnoid block,
4. Quality of patient positioning,
5. No of attempts,
6. Hemodynamic variability
7. Failure to perform spinal anaesthesia,
83
QUESTIONAIRRES USED IN THE STUDY
1) H/O Any Known allergy to any drugs
2) H/O Any systemic illness-Hypertension, Diabetes Mellitus, Bronchial
Asthma, Seizuredisorder, Pulmonary Tuberculosis, Peripheral vascular
disease
3) H/O of smoking ,COPD, Exertional dyspnoea,
4) H/O any cardiac or respiratory medications.
( Complaints related to CVS,RS, RENAL system)
84
GROUP FNB
S.NO. NAME AGE SEX WEIGHT
1 Pandiyan 60 M 58
2 Devi 38 F 62
3 Parameshwari 42 F 65
4 Bharathi 33 F 59
5 Jeyalaksmi 65 F 49
6 Arumugam 48 M 52
7 Parthiban 49 M 53
8 periyakka 46 F 58
9 Ganesan 57 M 56
10 Varathan 60 M 58
11 Ganthasamy 62 M 62
12 Kannayiram 68 M 58
13 Muthu 52 M 59
14 Petchi 54 F 64
15 Pothumponnu 55 F 52
16 Velu 49 M 53
17 Rakku 48 F 56
18 Santhanam 52 M 60
19 Sakkarai 53 M 63
20 kalyanamoorthi 56 M 62
21 Muthusamy 55 M 45
22 Pandiyaram 60 M 55
23 Ponnuselvam 62 M 60
24 Ilangovan 49 M 55
25 Annapoorani 64 F 62
26 Manikandan 48 M 70
27 Sasikala 40 F 85
28 Rani 44 F 58
29 Chellammal 65 F 65
30 Pooja 58 F 62
85
PR SPO2 SBP DBP vas at
block
vas at
positioning
for SAB
time to
perform
SAB
quality of
positioning
no of
attempts
92 98 140 70 4 3 136 1 1
100 99 120 80 4 2 117 1 1
80 98 130 80 4 3 130 1 1
82 99 120 80 5 3 162 0 3
86 97 140 80 3 2 124 1 1
89 98 130 90 3 2 136 1 1
94 99 100 70 4 3 141 0 1
96 98 110 80 4 3 152 0 2
83 99 100 80 3 2 112 1 1
84 97 130 70 5 3 159 0 2
85 98 140 90 4 3 144 0 2
87 99 120 80 4 3 150 0 2
84 98 130 90 4 2 124 1 1
83 99 140 90 3 2 136 1 1
92 99 120 80 3 2 109 1 1
77 98 110 80 3 2 139 1 1
79 99 110 80 2 1 104 1 1
85 100 130 90 3 2 119 1 1
87 99 130 80 4 3 133 1 1
89 97 110 70 4 3 160 0 3
77 99 140 80 3 2 120 1 1
80 98 130 80 3 2 137 1 1
100 97 150 80 4 3 140 0 2
89 99 110 80 3 2 130 1 1
90 98 130 80 3 2 139 1 1
85 97 120 80 3 2 120 1 1
79 98 110 70 4 3 135 1 1
92 99 110 90 5 3 149 0 2
95 97 140 80 3 2 117 1 1
82 100 130 70 3 2 115 1 1
86
GROUP FICB
S.NO. NAME AGE SEX WEIGHT
1 Palani 60 M 75
2 Palsamy 49 M 60
3 Palaniyammal 51 F 50
4 Periyya 54 M 59
5 amuthan 52 M 52
6 karthick 39 M 68
7 shanthi 66 F 63
8 chitra 59 F 65
9 madasamy 63 M 79
10 benazir 56 F 72
11 booma 47 F 65
12 karna 60 M 60
13 manikkam 45 M 53
14 nagarajan 50 M 60
15 kanthaiah 52 M 62
16 ganesan 54 M 55
17 gunasekaran 66 M 58
18 malarkodi 68 F 54
19 dhanam 63 F 50
20 poonkodi 49 F 63
21 muthammal 60 F 50
22 rakku 52 F 55
23 mugavar 70 M 57
24 ganesan 51 F 58
25 arasi 42 F 60
26 tamil 62 M 72
27 karuppaiah 55 M 75
28 madasamy 40 M 80
29 mokkan 49 M 64
30 chellappa 54 M 62
87
PR SPO2 SBP DBP vas at
block
vas at
positioning
for SAB
time to
perform
SAB
quality of
positioning
no of
attem
pts
100 99 140 90 4 2 120 1 1
88 98 140 70 3 1 110 1 1
78 99 120 80 3 1 92 1 1
80 99 130 90 3 1 100 1 1
82 98 130 90 3 1 90 1 1
84 99 110 70 3 1 100 1 1
86 97 140 80 3 1 102 1 1
88 98 120 90 3 1 100 1 1
92 99 130 90 4 2 122 1 1
80 98 130 90 3 2 121 1 1
88 99 120 90 3 2 117 1 1
90 98 130 80 3 1 100 1 1
82 99 110 70 3 1 102 1 1
92 97 120 80 3 1 103 1 1
86 99 120 80 4 2 115 1 1
88 100 130 90 3 1 105 1 1
96 99 130 90 5 2 125 0 1
77 99 140 90 3 1 97 1 1
76 97 130 80 3 1 90 1 1
100 98 110 70 4 2 123 1 1
88 99 140 80 3 1 100 1 1
82 97 130 80 3 1 102 1 1
77 99 150 90 3 1 115 1 1
84 98 140 70 3 1 108 1 1
86 97 120 90 3 1 104 1 1
88 98 130 80 3 0 90 1 1
99 100 120 90 4 2 120 1 1
105 99 120 70 4 2 127 0 1
92 99 130 90 3 1 105 1 1
90 98 140 80 3 1 110 1 1
88
INFORMED CONSENT FORM
1. I confirm that I have read and understood the information letter for the above
study and have had the opportunity to clear doubts.
2. I understand that my participation in the study is voluntary and that I’m free
to withdraw at any time, without giving any reason, without my medical care
or legal rights being affected.
3. I understand that the ethics committee and the regulatory authorities will not
need my permission to look at my health records both in respect of the current
study and any further research that may be conducted in relation to it even if
I withdraw from the trial. I agree to this access. However I understand that
my identity will not be revealed in any information released to third parties
or published.
4. I agree not to restrict the use of any data or results that arise from this study
provided such a use is only for scientific purposes.
5. I agree to take part in the above study.
Signature of the subject:
Signatory’s name:
Signature of the investigator:
Study investigator’s name:
Signature of impartial witness:
Name of impartial witness:
Date:
89
90
CERTIFICATE
This is to certify that this dissertation titled “ANALGESIA FOR
THE PERFORMANCE OF SPINAL ANAESTHESIA IN SITTING
POSITION IN THE PATIENTS WITH PROXIMAL FEMORAL
FRACTURE- A COMPARISON BETWEEN ULTRASOUND
GUIDED FASCIA ILIACA BLOCK AND FEMORAL NERVE
BLOCK” of the candidate DR.M.NISHANTHI with registration number
201720106 for the award of M.D degree in the branch of MD in
Anaesthesiology and Critical care. I personally verified the urkund.com
website for the purpose of plagiarism check. I found that the uploaded
thesis file containing from introduction to conclusion pages and result
shows 24 percentage of plagiarism in the dissertation.
DR.M.KALYANASUNDARAM M.D.,
Professor
Institute of Anaesthesiology
Madurai Medical College
Madurai-20
91
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