Med. J. Cairo Univ., Vol. 87, No. 1, March: 33-40, 2019 www.medicaljournalofcairouniversity.net Intraoperative Assessment of Ultrasound Guided Continuous Facia Iliaca Block (CFIB) Versus Continuous Lumbar Plexus Block (CLPB) in Patients Undergoing Fracture Neck Femur Fixation MOHAMMED A. HASSAN, M.D.; HALA E. MOHAMMED, M.D.; AMR Z. MANSOUR, M.D. and MOHAMMED A. MANSOUR, M.D. The Department of Anaesthesiology, Surgical ICU & Pain Management, Faculty of Medicine, Cairo University Abstract Lumbar plexus block is another form of deep blocks which is approached posteriorly. It is used Background: In the elderly and high risk patients, it is to provide anesthesia and/or analgesia for the entire logic to prefer local anaesthesia rather than general anaesthesia. The fascia iliaca compartment block is an easy, available distribution of the lumbar plexus. The needle used method for peri-operative analgesia in patients with painful in this block is deeply placed so, the potential conditions affecting the thigh, the hip joint and/or the femur. systemic toxicity is greater than it is with superficial Lumbar plexus block is another form of deep blocks which blocks [3] . is used to provide anesthesia and/or analgesia for the entire distribution of the lumbar plexus. As suggested by meta-analysis of previous Aim of Study: Intraoperative assessment of CFIB versus studies, the use of US guidance to provide nerve CLPB. block is more successful, faster to provide, has Material and Methods: 40 patients with fracture neck longer block time and carries less risk for compli- femur were randomized intone of 2 blocks, CFIB and CLPB. cations [4] . Results: CFIB was significantly superior to CLPB as regards shorter time for catheter insertion (CIT) (p<0.001), Patients and Methods earlier maximum motor block (p<0.001) and earlier peak of sensory block (p=0.008), intraoperative hemodynamic stability This prospective randomized controlled trail (p<0.001) while CLPB group showed significantly rapid onset of motor and sensory block (p<0.001, p<0.001). was carried out at department of Anesthesiology, Intensive Care and Pain Management, Kasr El- Conclusion: Continuous infusion fascia iliaca block gives Ainy Hospital from July 2014 to July 2015, after better quality analgesia. It is an easy procedure that could be done in the emergency room. It is faster, safer and more permission from the Hospitals Ethics committee applicable technique than continuous lumbar plexus block. and written informed patients consent. Key Words: Continuous facia iliaca block – Continuous lumbar plexus block – Intraoperative assessment. Forty patients, belonging to American Society of Anesthesiologists physical status (ASA) I to III, between age 40 to70 years old scheduled for frac- Introduction ture neck femur fixation were selected and divided IN the elderly and high risk patients, it is logic to into two equal groups 20 patients each (Group prefer local anaesthesia rather than general anaes- continuous fascia iliaca block (CFIB) and Group thesia [1] . continuous lumbar plexus block (CLPB)). Informed written consent was taken from the patients selected The fascia iliaca compartment block is an easy, for the study. Each patient was visited in the ward, available method for peri-operative analgesia in the evening before surgery for detailed pre- an- patients with painful conditions affecting the thigh, esthesia assessment. the hip joint and/or the femur [2] . Inclusion criteria: Correspondence to: Dr. Mohammed A. Hassan, • Patients American Society of Anesthesiologists E-Mail: [email protected] status (ASA) I to III. 33 34 CFIB Vs CLPB Fracture Neck Fixation • Age group: 40 to 70 years; scheduled for neck 1- Preoperative preparation: femur fracture fixation surgery. A- Preparation of the patient: 2 • BMI: 20-30kg/m . • Patient consent was taken for spinal and re- • Gender: Both sexes. gional anesthesia. • Patient accepted technique of treatment. • Maintain the therapeutic drugs (that are not contraindicated with regional anesthesia) till • Expected operative time 2-4 hours. morning of operation. Exclusion criteria: • Patient informed before the operation about • ASA physical status score of more than III visual analogue scales. 2 • Patient with BMI of more than 30kg/m . • Peripheral 18 gauge intravenous cannula was inserted and 10ml/kg/hr ringer solution was • Patients refusing the procedure or uncooperative given as preload. or needed GA. • Local sepsis or infection at puncture site. B- Preparation of the equipment and drugs: • Allergy to any of the drugs used in the study. • A standard general anesthesia tray is prepared. • Diabetic peripheral neuropathy or have a history • Standard regional anesthesia tray is prepared of stroke with lesion affecting the side to surgery with the following equipment: were excluded from the study. o Sterile towels and 4*4 gauze packs. • INR >1.5 or <12 hours post LMWH (many prac- o 25 G Quincke spinal needle. titioners consider a posterior approach to lumbar plexus comparable to central neuroaxial blockade) o Hyperbaric bupivacaine 0.5%. (Patton and Warman, 2012). o Isobaric bupivacaine hydrochloride 0.5% o Syringes with local anesthetic lidocaine Methodology in details: o Sterile gloves, marking pen and surface Preoperative assessment: electrode. Routine preoperative assessment was done for o Fentanyle and midazolam ampule. every patient including: o Peripheral nerve stimulator. A- History: o Ultrasound machine with a low-frequency For general or local anesthesia and any accom- (2-5 MHz) curved array probe and a high- panied complications, medical problem and history frequency (7-12 MHz) linear probe. of drug intake. o Catheter kit Contiplex®: B- Examination: - Including a 10cm stimulating needle 18 General examination: guage and a catheter 20 guage for CLPB. • Vital data (pulse, blood pressure and respira- - Including a 4cm stimulating needle 18 tory rate). guage and a catheter 20 guage for CFIB. • Clinical examination of the chest and heart. o Accufuser© Varicon silicone balloon infuser • Examination for jaundice, cyanosis, anemia, control pump. clubbing and edema. 2- Intraoperative management: Local examination: • Standard monitoring was applied (ECG, NIBP, • Airway examination. sPO2) were connected to the patient. Baseline • Examination to the site of injection. hemodynamic readings were recorded before starting the technique, at the beginning of C- Investigations: procedure and every 5 minutes. • Complete blood count. • Sedation was achieved with IV midazolam • Coagulation profile (prothrombin time and (0.03mg/kg) and Fentanyl (50-75 µg). concentration). • Then the patients were assigned to one of two • Liver and kidney function test. groups according to the block form: • Random blood sugar. 1- Group-1 (CFIB), no=20 • ECG. 2- Group-2 (CLPB), no=20 Mohammed A. Hassan, et al. 35 Patients were divided into two equal groups After local anesthetic skin infiltration "ligno- and were subjected to one of the regional blocks caine" 2%, 2-3ml, a 10cm, 20 gauge insulated first then spinal anesthesia. needle connected to a Peripheral nerve stimulator with initial current intensity of 1.0mA (2Hz, 0.1 Group-1 (CFIB): millisecond) was introduced in-plane with the The patient was placed in supine position. The probe. The lumbar plexus was finally identified landmarks for this block are the anterior superior by eliciting quadriceps contraction at current below iliac spine (ASIS) and the pubic tubercle of the 0.4mA. The catheter was then inserted in the needle same side. One middle finger was placed on the and advanced 3cm beyond the needle tip. The ASIS and the other middle finger on the pubic needle was then with drawn and the catheter was tubercle. A line was drawn between these two tunneled and fixed with a sterile medication. points. This line was divided into thirds (the index After negative aspiration, activation of the finger of both hands can be used). The point was blocks was performed by injecting 30ml and 40ml marked 1cm caudal from the junction of the lateral of 0.125% bupivacaine in CFIB and CLPB respec- and middle third. This is the injection entry point. tively. Injection was done incrementally over 5 With ultrasound (US) the aim is to visually identify minutes. Vital signs monitoring was continued for the femoral nerve and fascia iliaca and place the 30 minutes after bolus dose. local anaesthetic beneath the fascia, lateral to the femoral nerve. Sensory blockade was assessed in the cutaneous distribution of the femoral nerve (anterior aspect A high frequency ultrasound probe (13-16 MHz, of the thigh), the lateral femoral cutaneous nerve linear array) was used in a transverse direction (lateral aspect of the thigh) and the obturator nerve over the anterior thigh below the inguinal ligament. (medial aspect of the thigh) by using cold percep- The needle was advanced until the tip is placed tion or pinprick. Assessment was done using the underneath the fascia iliaca and the catheter was 3 point scale for sensory assessment: 0=Complete introduced. loss, 1=Partial loss, 2=Normal sensation. Group-2 (CLPB): Motor blockade was assessed by femoral and The patient was placed in the lateral decubitus obturator nerve function (knee extension and thigh position with the side to be operated upper most, adduction). Movement was classified according to and the area was prepared and draped in a sterile modified Bromage scale: No weakness =0, partial fashion. The ultrasound scan was performed using weakness=1, almost complete weakness =2, com- a low frequency, 2-5 MHz, curved array transducer. plete weakness=3. Liberal amounts of ultrasound gel were applied to All assessements were undertaken approximate- the skin over the lumbar paravertebral region for ly every two minutes for 30 minutes. The block acoustic coupling and the ultrasound transducer was considered unsuccessful if the patient failed was positioned approximately 3-4cm lateral and to develop decreased sensation over the ipsilateral parallel to the lumbar spine, with its orientation marker directed cranially, so as to produce a lon- distal thigh and weakness upon knee extension relative to the contralateral limb within 30 minutes.