Fascia iliac compartment blocks

[gasman]

For a variety of reasons, the anaesthetists in Canberra (and I suspect most of Australia) are moving away from epidural blocks for hip and knee replacement surgery. The main concern is the higher-than-we-thought incidence of major spinal cord complications probably secondary to the use of Clexane post-op in these patients.

We have had a huge shift to GA plus fascia iliac blocks (3-in-one lumbar plexus blocks).

The fascia iliac block is put in either before induction, or during the emergence period.

The technique is to use a sterile epidural kit and threading an epidural catheter into the fascia iliaca compartment. This lies about 4cm lateral to the femoral artery. The 2 "pops" are felt as the fascia lata and then the fascia iliaca. Theoretically the higher you thread the catheter, the more of the lumbar plexus (in particular the lat. cut. n of the thigh) you can block. A weak solution (eg bupivacaine 0.125%) is run in at 10mL/hr with boluses if required)

The advantages are very easy insertion, almost risk-free (well away from the femoral artery and even lateral to the femoral nerve), no hemodynamic consequences of sympathetic blockade, and no narcotic involved. Patients usually require a morphine PCA as well, but their narcotic requirements are markedly reduced.

The disadvantages are variable efficacy (there is no guarantee that your catheter will feed caphalad), and a difficulty in fixation leading to early failure if dislodged.

I am interested in international experiences with epidurals in this patient group and others experience with fascia iliac blocks.

[Dr.Rengarajan M.D]

In India we do the whole procedure in Epidural Anesthesia.
I found Psoas compartment block with Sciatic nerve block con be used for any of the lower limb surgeries.

[combest]

I have started doing some fascia iliaca blocks and am thus far very pleased with the results.  Quick, low-risk as previously described, require no nerve stimulator, very comfortable for the patient.  I have done both single-shot with as much as 40cc of LA and can place catheters at one hospital at which I have privileges.  I did one 4 days ago for post op pain control for a patient having a BKA.  I really thought I would not get adequate analgesia because of a lack of effect on the sciatic nerve, but apparently, the 40cc volume tracked retrograde enough that his pain control was complete for about 6 hrs (no catheter allowed in this case.).  I have provided them for Total knee replacements, also.

[in2b8r]

I have done many 3in1 blocks.  They are great for peds.  I used to do them for hip fractures, tkr and thigh procedures.  I thought they worked well with some variability.  I found however a continuous femoral block with a stimulated catheter to be more efficacious for total knees.  for hips a psoas block would be helpful also.

[carmanucor]

Good nigth. sorry my bad English

1 - I prefer femural block with a stimulating catheter and a continuous infusion with a elastomeric pump to Total Knee replacement, with GA or SAB.
2 - For Hip replacement I do weekly a posterior approach lumbar plexus , with a stimulating catheter for analgesia with a SAB .

Good results

[carmanucor]

Sorry. I'm a Portughese anesthetist and I don't know what is Clexane. Can you explain what is it? thank you