11/13/24, 7\:20 PM Guide | Fascia iliaca compartment block

Fascia iliaca compartment block

Table of contents

Introduction

The fascia iliaca compartment block (FICB) is a common procedure carried out in the adult emergency department,
particularly in the context of a fractured neck of femur (NOF). It provides epain relief for patients and reduces the use of
opiates, which is benedelirium and opioid toxicity in elderly patients.
This guide provides a step-by-step approach to performing a fascia iliaca compartment block in an OSCE setting. It is
NOT intended to be used to guide patient care.
This article uses the ‘landmark technique’ (the ‘two pop’ method). Some organisations recommend an ultrasound-guided
approach for this procedure, so always check and follow local guidelines.

Fascia iliaca compartment block

A FICB involves injecting local anaesthetic into the fascia iliaca compartment to provide pain relief, commonly following a hip
fracture. The aim is to introduce local anaesthetic into the potential space located below the fascia iliaca, allowing it to target
the three nerves in the area\:
The femoral nerve
The lateral cutaneous nerve of the thigh
The obturator nerve
Common indications for this procedure include\:
Fractured neck of femur
Fractured femoral shaft
Soft tissue injury to the hip

Pre-procedure

Check for contraindications

Check for any absolute or relative contraindications prior to performing the procedure\:
Absolute contraindications
Patient refusal
Local skin infection in the groin area
Allergy to anaesthetic agent
Relative contraindications
Uncooperative patient
Bleeding disorder, anticoagulants, or coagulopathy (including INR >1.5 or platelets \<50)
Previous femoral bypass surgery
A senior decision maker should determine whether the risk outweighs the bene
Using an ultrasound-guided technique can reduce the risk in patients with a bleeding disorder or taking anticoagulants.

Review imaging

Ensure there is a recent X-ray which shows a fractured neck of femur or a femoral shaft fracture, and note which side.
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Emergency medication

Ensure you have access to the following emergency drugs in case of local anaesthetic toxicity or a severe allergic reaction\:
Lipid emulsion solution (Intralipid ®
)\: follow local guidelines in the event of local anaesthetic systemic toxicity
Adrenaline (500 micrograms, 1\:1000 (1 mg/mL) intramuscular injection in the event of anaphylaxis

Local anaesthetic dose

Levobupivacaine is the most commonly used long-acting local anaesthetic for FICB in the UK. The maximum safe dose
of bupivacaine or levobupivacaine is 2 mg/kg.
Be aware that di
0.25% levobupivacaine contains 2.5 mg/mL
0.5% levobupivacaine contains 5 mg/mL
A 60 kg patient can have a maximum dose of 120 mg of local anaesthetic (2 mg/kg). This would be equivalent to 48 mL of
0.25% levobupivacaine or 24 mL of 0.5% levobupivacaine.
Check your local guidelines for weight-related local anaesthetic dosing. These are often set below the maximum dose, in
order to avoid toxicity.
*
Table 1. Example dosing of 0.25% levobupivacaine
Patient weight Dosage Volume
Less than 50 kg 75 mg 30 mL
More than 50 kg 100 mg 40 mL
*
refer to local guidelines

Gather equipment

Clean a procedure trolley using a disinfectant wipe.
Gather the equipment required for the procedure and place it on the clean bottom shelf of the trolley\:
Antiseptic solution with applicator (e.g. chlorhexidine applied with ChloraPrep™)
Apron and sterile gloves
Sterile
Sterile gauze
Long-acting local anaesthetic (usually levobupivacaine 0.25%, check local policy)
Needle and syringe for drawing up long-acting local anaesthetic (e.g. drawing-up needle and 2 x 20 mL syringe or 1 x 50 mL
syringe)
Blunt needle to perform the FICB (e.g. red 18G blunt drawing-up needle)
Short-acting local anaesthetic for skin (e.g. 1% lidocaine, drawing-up needle, 5 mL syringe and narrow bore needle for skin
in
Small dressing
Skin marker
Small wound dressing

Introduction

Wash your hands.
Don PPE if appropriate.
Introduce yourself to the patient, including your name and role.
Con
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Brie
Risks of FICB
Block failure (20%)
Intravascular injection and local anaesthetic toxicity
Nerve damage
Bleeding
Infection
Allergy/anaphylaxis
Gain verbal consent to proceed.
Check if the patient has any allergies (e.g. latex, local anaesthetic).

Preparation

Ensure that your patient is in a comfortable position on the bed.
This includes\:
Lying
The a
Check that the patient has working IV access.
Attach your patient to monitoring and take a baseline set of observations before you proceed.

Identify the correct landmarks

The correct landmarks must be identi
Firstly, the anterior superior iliac spine (ASIS) must be identi
Next, identify the pubic tubercle of the pelvis
Identify the inguinal ligament, which runs between the ASIS and pubic tubercle
Divide the inguinal ligament into thirds (using the index and middle
and medial thirds)
The injection site is 1 - 2 cm below the junction between the middle and outer (lateral) third
Mark the injection site with a skin marker or with pressure from the blunt end of a needle cover
Palpate for the femoral artery to ensure the injection site is away from the large neurovascular bundle found in the thigh
It is important that you identify the femoral artery before attempting to inject. If in doubt, check with a senior clinician.

Set up the sterile

1. Wash your hands and don an apron.
2. Remove the outer packaging from the sterile
3. Place the sterile
surface of the
4. Use an aseptic non-touch technique (ANTT) to place the antiseptic solution, blunt
onto the sterile
5. Wash your hands again.
6. Don sterile gloves and clean about 10 cm of the patient’s skin around the injection site.
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7. Check the expiry date of the local anaesthetic and ask your assistant to open the vial. Use a needle and syringe to draw up
the required amount of levobupivacaine 0.25% (or alternative) without your sterile equipment touching a non-sterile surface.
8. The levobupivacaine can be drawn up in 2 x 20 mL syringes or 1 x 50 mL syringe (the latter method prevents switching
between syringes whilst performing the block).

Perform the procedure

1. Inlocal anaesthetic (e.g. 1% lidocaine), allowing su
work.
2. Attach the syringe with the long-acting local anaesthetic (e.g. 0.25% levobupivacaine) to a clean 18G blunt drawing-up
needle.
3. Insert the needle, perpendicular to the skin, through the injection site. Push the needle into the skin and pause once you are
through.
4. Gently advance the needle further into the skin and feel for the ‘two pops' as the needle passes through two layers of fascia.
A blunt needle is used in the landmark technique so that a ''pop'' can be felt when passing through the fascial planes.
Structures pierced during the procedure
Skin
Subcutaneous tissue
Fascia lata (
Fascia iliaca (second "pop")
5. Palpate the femoral artery and ensure that you remain lateral to it.
6. Gently aspirate to ensure you are not in a blood vessel. If you see blood, do not inject local anaesthetic.
7. The needle will need to be repositioned if a small amount of blood is aspirated. If you see frank blood in the needle or think
you have punctured the femoral artery or vein, remove the needle entirely, apply pressure to the area and seek senior
assistance.
8. If no blood is aspirated, slowly inject your local anaesthetic. There should be little or no resistance as the fascia iliaca
compartment opens up.
9. If resistance is felt, you are likely not in the correct space and may be in the iliacus muscle. If in the iliacus muscle, you should
withdraw the needle 1-2 mm and re-aspirate before attempting to inject the local anaesthetic again.
10. If using 2 x 20 mL syringes, unscrew the
compartment) and replace it with your second syringe of local anaesthetic.
11. If using 1 x 50 mL syringe, slowly inject the total pre-
ensure you are not in a blood vessel.
12. Observe for signs of local anaesthetic toxicity (see below).
13. When all the local anaesthetic has been injected, slowly remove the need and hold pressure on the area with sterile gauze.
Apply a small dressing.
14. Take regular observations for up to 45 minutes as per local guidelines (e.g. 5, 10, 15, 30 and 45 mins).
13. Stay close to your patient and document your procedure, ensuring the dose of local anaesthetic prescribed is clearly
documented in the drug chart and the patient's notes.

Management of complications

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Local anaesthetic toxicity

If your patient shows any signs of local anaesthetic toxicity, including\:
Sudden alteration in mental status
Perioral numbness or paraesthesia
Severe agitation
Loss of consciousness, hypotension, seizures or arrhythmias
Hypertension and tachycardia
Tinnitus
Dizziness or lightheadedness
Metallic taste
Immediately cease administration and call for help.
Ask a colleague to call the resuscitation team (2222) while you prepare to administer the lipid emulsion.

Anaphylaxis

If your patient starts to show signs of anaphylaxis, including\:
Swelling of the throat and tongue
Di
Di
Wheezing
Confusion
Rash
Hypotension
Loss of consciousness
Immediately cease administration and call for help.
Ask a colleague to call the resuscitation team (2222) and commence management with the administration of intramuscular
adrenaline. Then, continue to follow the Resus Council's algorithm for managing anaphylaxis.

To complete the procedure…

Explain to the patient that the procedure is now complete.
Thank the patient for their time.
Dispose of PPE and other clinical waste into an appropriate clinical waste bin.
Inform the nursing stavital signs.

Documentation

Document details of the procedure in the patient’s notes including\:
Your personal details including your name, job role and GMC/NMC number
The date and time the procedure was performed
That you have gained verbal consent
The indication for the FICB
The amount of local anaesthetic used
The side of the FICB
That you palpated the femoral artery
Any complications
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References

Forbes, A. et al. Fascia iliaca compartment block. R C E M L e a r n i n g . Published 27/02/2023. Available from [LINK]
O'Reilly, N et. al. Fascia iliaca compartment block. N I H n a t i o n a l l i b r a r y o f m e d i c i n e . Published 24/04/2019. Available from
[LINK]
Source\: geekymedics.com
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