To perform a USGFICB, two approaches exist. Both have the goal of injecting local anesthetic into the compartment lateral to the femoral nerve, which lies lateral and adjacent to the vascular bundle (see Figure 1). The two approaches are the infrainguinal (see Figure 2A) and the suprainguinal (see Figure 2B).
Figure 1. The inguinal ligament may be divided into thirds, with the target site for injection being the lateral one-third mark. This lies lateral to the femoral nerve and vasculature.
Figure 2. A: In the infrainguinal approach, the fascia lata and fascia iliaca form a “bow tie” when overlapping between the sartorius caudad and internal oblique cephalad, with underlying iliacus muscle spanning over the ilium. B: In the suprainguinal approach, the sartorius overlies the iliacus muscle on its lateral border, with the fascia iliaca separating the two muscles. The femoral nerve and vascular bundle lie medial to the iliacus muscle, and the lateral femoral cutaneous nerve lies between the muscle bodies.
Supplies
- High-frequency linear transducer (6–10 MHz) with sterile lubricant
- 0.5% ropivacaine (5 mg/mL): dilute 30 mL 0.5% ropivacaine into 30 mL 0.9% normal saline
- Max dose is commonly considered 3 mg/kg.
- Ropivacaine is the preferred local anesthetic due to its long-acting duration with a greater safety profile than bupivacaine.13
- Mixing of local anesthetics is not currently advised due to less predictable onset, duration, and potency.13
- 22-gauge blunt-tipped echogenic needle (Whitacre and Sprotte needles are blunt-tipped needles, which provide better tactile feedback when “popping through” the fascia lata and fascia iliaca.)
- IV tubing connected to a 30 or 60 mL syringe
- Chlorhexidine scrub or alcohol prep sponge
- Local anesthetic for cutaneous anesthesia (eg, 12% lidocaine without epinephrine)
- Personal protection equipment including sterile gloves
- Second provider present for assistance
- Airway supplies and 20% lipid emulsion available
With the above supplies prepared and on standby, perform a preprocedure scan to determine the patient’s specific anatomy. Prepare the selected injection site with chlorhexidine or isopropyl alcohol. A skin marker may help maintain proper orientation to the injection site. Next, flush the premixed 30 mL of ropivacaine and normal saline through the line and echogenic needle.
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5 Responses to “Control Hip Fracture Pain Without Opioids Using Ultrasound-Guided Fascia Iliaca Compartment Block”
January 27, 2018
Ron BraceThe diagram, first color coded one showing locations of Fem nerve vein and artery is seriously mislabeled and a correction need be done; Femoral Vein is in wrong place, as is the Femoral artery – and the fem artery is mislabeled
I am sure by now a thousand people have written about it!
https://www.acepnow.com/wp-content/uploads/2018/01/ACEP_0118_pg20a.png
January 28, 2018
Robert A.Great article. I think Figure 1 is mislabeled: Femoral artery is mislabeled as “Fem V.” and Femoral vein mislabeled as “Fem N. (red)”.
February 5, 2018
HosamIn illustration, I think that order of structures are not proper.it is vien artery nerve from medial to lateral
February 5, 2018
MikeHi, picture 1 seems to have some errors. There are two structures markes Fem N, one of them in red which is likely supposed to be the Fem Artery. If that structure is supposed to the fem artery it is incorrectly positioned medial to the femoral vein when it should be lateral
February 5, 2018
Dawn Antoline-WangThank you to everyone who pointed out the error in Figure 1. The image has been corrected.