Fascia Iliaca Block(FIB)

STUDENT NUMBER: 21408517

 Introduction:
Fascia iliaca block (FIB) is a local anaesthetic nerve block which helps to block the lateral cutaneous nerve and the femoral nerve of the
thigh. The fascia iliaca block which spreads to the fibrous layer is called Fascia iliaca, without direct nerve contact. The FIB can deliver
excellent analgesia for hip fracture patients without the side effects of the administration of opioids and non-steroids anti-inflammatory
drugs (NSAID). Fascia iliaca can be performed by using ultrasound or with a loss of resistance technique, the latter sometimes referred to
as the "two-pop-method". FIB works by affecting the femoral, obturator and the lateral cutaneous nerves with a local anaesthetic. This
procedure is performed to block pain signals from traveling along the femoral nerve from the thigh or knee to the brain.
Undertreated pain and inadequate analgesia are important risk factors for development of post-operative cognitive impairment and
delirium in patients following hip fracture. Not only is cognitive impairment common in patients suffering hip fractures, but the pathology
has severe implications for the perioperative management and rehabilitation of such patients, leading to a longer length of hospital stay
and greater mortality. Cognitive impairment encompasses a spectrum of conditions, including acute delirium and chronic dementia.
Irrespective of aetiology, cognitive impairment in patients following a hip fracture can adversely affect the patient’s ability to self-care,
independently mobilize, request nursing assistance and engage with other post-operative recovery processes. Post-operative delirium in
elderly patients is also associated with increased one-year mortality and worse functional outcomes. Hence, early intervention to reduce
the risk of cognitive decline in patients with hip fracture represents a clear opportunity to improve post-operative outcomes and
recovery.
An estimated number of 65,000 patients are admitted with hip fractures in the UK. These figures are set to increase to numbers beyond
100,000 or above by 2020. The cost for this is around 2 billion pounds a year for the NHS alone. These fractures affect more on elderly
people who leave significant co-morbidities and use of multidrug therapy.
Research has shown that improper pain management have significant emotional and physical effects on patients, which may delay
operative management and post-operative recovery. Studies report that pain management on the elderly patients with limb fractures is
highly sub-optimal with some suggesting only 2% obtain adequate pain relief.
Neck of Femur Fracture (NOF) could be very painful. Conventional analgesia usually causes undesirable side effects in patients,
especially opioids can lead to respiratory depression, confusion and hypotension. Renal impairments can be caused by non-steroid anti-
inflammatory drugs. FIB can provide effective and a safe form of pain management for patients with NOF.
Definition of Fascia Iliac block:

Fascia iliaca block (FIB) is a local anaesthetic nerve block used for hip
fractures to reduce pain, prevent delirium and the need for systemic
analgesia. FIB is administered on hip fracture patients before their
operation.

Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier

Ltd. All rights reserved.
Anatomy:

The nerve supply of the lower extremity is provided through four major
nerves: the sciatic nerve, the femoral nerve, the obturator nerve and
the lateral cutaneous nerve of the thigh. The femoral, obturator and
lateral cutaneous nerves of the thigh all arise from the lumbar plexus.
The sciatic nerve arises from the lumbar and sacral plexuses.
Landmark for injection:

• Lateral border of pubic symphysis (o cm)

• Mark as one third (roughly 3cm)
• Mark at two thirds (approximately 6cm)
• Mark anterior superior lilac (approximately 9cm)
Landmark procedure:

The landmarks for the procedure are the anterior superior iliac spine (ASIS)
and the ipsilateral pubic tubercle. Place one finger on each of these bony
landmarks and draw an imaginary line between them. Using your index
fingers divide this line into thirds. At the junction of the lateral 1/3 and
medial 2/3 make a mark. Your insertion point will be 1cm distal/caudal to
this mark
The injection site for a right-sided fascia iliaca block. Divide a line between
the ASIS and pubic tubercle (PT) into thirds. The left index finger (in this
case) marks the junction of the lateral third and medial two thirds of the
line.
Landmarks projected onto the skin. Anterior superior iliac spine (ASIS),
pubic tubercle, with the adjoining line divided into thirds. The femoral
artery is marked with a solid line, with an estimation of the position of the
femoral nerve marked with a dotted line. The injection point is marked with
an ‘X’, and is 1cm caudad to the junction of the lateral 1/3 and medial 2/3
of the line.
Indication:

• The purpose of FIB is to reduce the demand for systematic

analgesia like, NSAID, opioids, along with side-effects.
• Pre-operative pain reliever with femoral fractures.
 Contra Indications:

• Patient refusal
• Previous allergic reaction to local anaesthetic (LA).
• Infection or inflammation over the site.
• Obesity
• Anticoagulation- International Ratio >2
• Consider recent clopidogrel/high dose aspirin/low molecular weight heparin.
• Discuss with senior clinician and use clinical judgement.
• Past surgical history of vascular operations
• Hypovolaemic shock
• Unable to find femoral artery
Performing the block:

• Confirm the patient and reason for the procedure

• Obtain verbal consent
• Explain the procedure to the patient and possible side effects
• Intravenous access
• Make sure appropriate assistance is available
• Position the patient and perform landmark
• Use aseptic technique
• Surgical sight marking
• Perform the procedure
• Vital signs are checked as guided
• Documentation
Complication:

• Local anaesthetic toxicity

• Infection
• Allergic reaction
Side effects:

• Hypotension
• Bleeding
• Infection
• Failure of the procedure
Summary:

The fascia iliaca block performed by the landmark technique is

inexpensive, safe and easy to perform. It delivers effective pain relief
whilst avoiding the undesirable side-effects of certain other forms of
analgesia. FIB delivers excellent pain management. Delivering large
volumes of low concentration local anaesthetic helps to maximize the
benefits of the block, whilst following the well-established techniques
set out above to help to minimize complications. It is important to
remember to always work under safe conditions. Ensure the performer
has been trained and are competent in performing the Fascia Iliaca
block. Make sure the staff have been provided with regular training/
refreshing the necessary skills.
References:

• FASCIA ILIACA COMPARTMENT BLOCK: LANDMARK APPROACH

PREPARED BY: DR. NIA WYN DAVIES
• C. Range, C. Egeler. “Fascia Iliaca Compartment Block: Landmark and ultrasound
approach,” Anaesthesia Tutorial of the Week 193, August 23rd 2010.
• (www.frca.org.uk).
• http://www.nhfd.co.uk/nhfd/nhfd2015reportPR1.pdf
• http://www.nice.org.uk/nicemedia/pdf/fnfscopefinal.pdf.
• L. J. White, J. D. Cooper, R. M. Chambers, and R. E. Gradisek. “Prehospital use
of analgesia for suspected extremity fractures,” Prehospital Emergency Care, vol. 4,
no. 3, pp. 205–208, 2000.
• C. C. McEachin, J. T. McDermott, and R. Swor. “Few emergency medical services
patients with lower-extremity fractures receive prehospital analgesia,” Prehospital
Emergency Care, vol. 6, no. 4, pp. 406–410, 2002.
References(continued):

 •L. Hanna, A. Gulati, and A. Graham. “The Role of Fascia Iliaca

Blocks in HipFractures: A Prospective Case-Control Study and
Feasibility Assessment of aJunior-Doctor-Delivered Service,” ISRN
Orthopedics, Volume 2014 (2014), Article ID191306, 5 pages.
 References(continued):

• https://quizlet.com/101645604/lower-limb-anatomy-eliot-flash-cards/
• https://en.wikipedia.org/wiki/Lumbar_plexus
• http://www.chiropractic-help.com/upper-leg-pain.html
• http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?11/48/12038
• https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf
• https://www.resus.org.uk/anaphylaxis/emergency-treatment-of-anaphylactic-
reactions
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