ANALGESIA FOR THE PERFORMANCE OF SPINAL ANAESTHESIA …

ANALGESIA FOR THE PERFORMANCE OF SPINAL

ANAESTHESIA IN SITTING POSITION IN THE PATIENTS

WITH PROXIMAL FEMORAL FRACTURE-A COMPARISON

BETWEEN ULTRASOUND GUIDED FASCIA ILIACA BLOCK

AND FEMORAL NERVE BLOCK

DISSERTATION SUBMITTED FOR THE DEGREE OF DOCTOR

OF MEDICINE

BRANCH – X (ANAESTHESIOLOGY)

REG.NO.201720106

THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY

CHENNAI, TAMILNADU

MAY-2020

CERTIFICATE BY GUIDE

INSTITUTE OF ANAESTHESIOLOGY AND CRITICAL CARE

This is to certify that this dissertation entitled “ANALGESIA FOR

THE PERFORMANCE OF SPINAL ANAESTHESIA IN SITTING

POSITION IN THE PATIENTS WITH PROXIMAL FEMORAL

FRACTURE- A COMPARISON BETWEEN ULTRASOUND

GUIDED FASCIA ILIACA BLOCK AND FEMORAL NERVE

BLOCK” is a bonafide and genuine research work done by

DR.M.NISHANTHI in partial fulfillment of the requirement for the

degree of MD in Anaesthesiology and Critical care.

Dr.R.KAVITHA. M.D.,

Assistant Professor

Institute of Anaesthesiology

Madurai Medical College

Madurai-20

DR.R. SELVAKUMAR M.D., D.A., D.N.B

Professor



Madurai-20

Date:

Place:

CERTIFICATE BY HEAD OF THE DEPARTMENT

INSTITUTE OF ANAESTHESIOLOGY AND CRITICAL CARE

This is to certify that this dissertation entitled “ANALGESIA FORTHE

PERFORMANCE OF SPINAL ANAESTHESIA IN SITTING





Dr.M.NISHANTHI in partial fulfillment of the requirement for the degree

of MD in Anaesthesiology and Critical care under the guidance of

Prof.Dr.R.SELVAKUMAR M.D., D.A., DNB Institute of

Anaesthesiology and critical care.

DATE :

PLACE: Madurai

Prof.Dr.M. KALYANASUNDARAM M.D.,

Director,

Institute of Anaesthesiology,

Govt. Rajaji Hospital & Madurai Medical College

Madurai.

ENDORSMENT BY THE DEAN

GOVERNMENT RAJAJI MEDICAL COLLEGE AND HOSPITALS

This is to certify that this dissertation entitled “ANALGESIA FOR THE

PERFORMANCE OF SPINAL ANAESTHESIA IN SITTING





Dr.M.NISHANTHI in partial fulfillment of the requirement for the degree

of MD in Anaesthesiology and Critical care under the guidance of

Prof.Dr.R.SELVAKUMAR M.D.,D.A.,D.N.B Institute of

Anaesthesiology and critical care, Professor, Institute of Anaesthesiology

and critical care.

Date:

DR.K. VANITHA M.D.,DCH Place: Madurai Dean

Govt. Rajaji Hospital


Madurai.

DECLARATION

I, Dr.M.NISHANTHI solemnly declare that, this dissertation titled

“ANALGESIA FOR THE PERFORMANCE OF SPINAL

ANAESTHESIA IN SITTING POSITION IN THE PATIENTS

WITH PROXIMAL FEMORAL FRACTURE- A COMPARISON

BETWEEN ULTRASOUND GUIDED FASCIA ILIACA BLOCK

ANDFEMORAL NERVE BLOCK” has been done by me. I also

declare that this bonafide work or a part of this work was not submitted by

me or any other for any award, degree or diploma to any other University

or board either in India or abroad.

This is submitted to The Tamilnadu DR.M.G.R Medical University,

Chennai in partial fulfillment of the rules and regulations for the award of

Doctor of Medicine degree branch X (Anaesthesiology) to be held in MAY

2019.

Date:

Place: Madurai Dr.M.NISHANTHI

ACKNOWLEDGEMENTS

With great reverence, I extend my deep sense of gratitude to

respected guide Dr.R.Selvakumar M.D.,D.A.,D.N.B., Professor,

Institute of Anaesthesiology and critical care, for his advice, able

guidance, constant inspiration, constructive criticism and novel

suggestions throughout my post graduate study, without whose initiative

and enthusiasm, this study would not been completed.

My sincere thanks to Dr.M.KALYANASUNDARAM M.D.,

DIRECTOR, Institute of Anaesthesiology and critical care who supported

and guided me in each and every step of my work.

My sincere thanks to Dr.R.KAVITHA M.D., Assistant Professor,

Institute of Anaesthesiology and critical care who supported and guided

me in each and every step of my work.

I am thankful to all my Assistant Professors, Professors, My

Colleagues, Seniors, Juniors and All Other Staff Members Institute of

Anaesthesiology And Critical Care for their constant support and guidance

in completing this study.

I thank my Parents and Family members for their support during the

course of study.

I also thank my collaborating department, Department of

orthopedic surgery who allowed me to perform my study at their theatre.

I thank The Dean, Government Rajaji Hospital and Madurai

Medical College, Madurai for permitting me to utilize the college and

hospital for my study. Lastly, I sincerely thank all of my patients for their

kind cooperation during the course of the study.

Date:

Place: Madurai Dr.M.NISHANTHI

TABLE OF CONTENT

S.NO TITLE PAGE NO

1. INTRODUCTION 1

2. CLINICAL ANATOMY-LUMBAR PLEXUS 2

3. FEMORAL NERVE 9

4. FASCIA ILIACA COMPARTMENT 14

5 CLINICAL PHARMACOLOGY LIGNOCAINE 17

6 CLINICAL PHARMACOLOGY BUPIVACAINE 19

7 ULTRASONOGRAM 22

5. FASCIA ILIACA COMPARTMENT BLOCK 29

6. FEMORAL NERVE BLOCK 36

7. SPINAL ANAESTHESIA 42

8. REVIEW OF LITERATURE 49

9. AIM OF STUDY 57

10. MATERIALS AND METHODS 58

11. STATISTICAL ANALYSIS 61

12. OBSERVATION 62

13. RESULTS 74

14. DISCUSSION 75

15. CONCLUSION 78

16. BIBILIOGRAPHY 79

17. ANNEXURES

81 1.PROFORMA

2.MASTER CHART

3.ETHICAL CLEARANCE

4.PLIAGRASIM CERTIFICATE

1

INTRODUCTION

Fracture of the femur occurs most commonly after trauma or trivial

fall especially in the elderly. This causes significant morbidity. Surgery for

fracture femur may be done under regional or general anesthesia. It has

been shown that regional anesthesia is associated with lesser morbidity and

mortality compared to general anesthesia.

Regional anesthesia was associated with a lower adjusted odds of

mortality compared to general anesthesia. Thus, femur fracture surgeries

are performed safely under regional anesthesia. Subarachnoid block is

administered in either the sitting or lateral position. Positioning patients for

spinal anesthesia with fractured femur is challenging because even

minimal overriding of the fracture ends is exceedingly painful.

Providing analgesia before positioning not only increases patient

comfort but also improves positioning and successful spinal block. So this

study is conceived to compare the efficacy of two different block for

providing analgesia during positioning for spinal anaesthesia.

2

CLINICAL ANATOMY

Since femoral nerve and obturator nerve, lateral cutaneous nerve

originate from lumbar plexus. First this chapter explains about lumbar

plexus.

LUMBAR PLEXUS:

The lumbar plexus is formed by upper four lumbar nerves. After

emerging from the intervertebral foramina each nerve divides into dorsal

ramus and ventral ramus. Dorsal rami of lumbar plexus supplies cutaneous

nerve supply to gluteal region. The ventral rami enter the substance of the

psoas major muscle, within the muscle the rami from the upper 4 lumbar

nerves join each other to form the lumbar plexus. Part of 4th lumbar nerve

joins the 5th lumbar to form the lumbosacral trunk, which takes part in

forming the sacral plexus. The greatest part of the 1st lumbar nerve is

continued into a nerve trunk that divides into iliohypogastric and

ilioinguinal nerve. The rest of the 1st lumbar nerve is joined by a branch

from 2nd lumbar to form the genitofemoral nerve. The 2nd ,3rd and greater

part of the 4th lumbar nerve divides into anterior and posterior division. The

posterior division which are large form the femoral nerve. The posterior

divisions of L2 and L3 also gives rise to lateral cutaneous nerve of thigh.

The anterior division unites to form the obturator nerve . Other branches

are to Psoas major(L2-L3), Quadratus lumborum T12,L1,L2,L3, Psoas

minor L1 and Iliacus L2,L3.

3

LUMBAR PLEXUS:

4

LATERAL CUTANEOUS NERVE OF THIGH

The lateral cutaneous nerve of thigh is derived from the dorsal

divisions of L2 L3 , intial part lies within the psoas major . Emerging from

the lateral border of the muscle the nerve runs downwards, laterally and

forward over the iliacus muscle to reach the anterior superior iliac spine. It

enters thigh by passing behind lateral end of inguinal ligament. It divides

into anterior and posterior branches through which it supplies the skin on

the anterolateral part of the thigh right up to the knee. While the nerve is

over the iliacus muscle, it is related to the caecum on the right side and to

the part of descending colon on the left side.

5

OBTURATOR NERVE

This nerve is formed by union of roots arising from L2, L3, and L4 .Its

course can be considered in three parts.

1. The first part runs downwards in the substance of the psoas major.

2. The second part of the nerve lies in the lateral wall of the true pelvis.

It runs downwards and forwards lying over the obturator internus

muscle.

3. The third part of the nerve lies in the thigh. As it passes through the

obturator foramen, it divides into anterior and posterior divisions

The anterior division lies in front of the obturator externus (above) and

the adductor brevis (below): It lies behind the pectineus (above) and the

adductor longus (below).

The posterior division lies in front of the obturator externus (above)

and the adductor magnus (below). It is behind the pectineus (above) and

the adductor brevis (below).

Muscular branches

Branches arising from the anterior division supply:

a. Obturator externus

b. Adductor longus

c. Gracilis

d. Pectineus and the adductor brevis (sometimes).

6

Branches of the posterior division supply:

a. Obturator externus

b. Adductor brevis

c. Adductor magnus.

Cutaneous branches

Anterior division supplies the skin of the lower medial part of the

thigh.

Articular branches

These are given off to the hip joint and to the knee joint. The latter

is a continuation of the posterior division and travels along the femoral

artery.

Vascular branches

The anterior division supplies the femoral artery.

7

OBTURATOR NERVE

8

ACCESSORY OBTURATOR NERVE

Arising from L2 and L3 this nerve runs downwards along medial

margin of Psoas major in company with the external iliac vessels. It does

not enter the true pelvis, but passes behind the inguinal ligament deep to

the pectineus to reach the thigh. The nerve ends by supplying the pectineus

and the hip joint and communicates with the anterior division of the

obturator nerve

9

FEMORAL NERVE

The femoral nerve arises from the ventral rami of L2, L3 and L4

within substance of the psoas major. Course begins with it descends

through and emerges from the lateral border above the inguinal ligament

.Then it now comes to lie in the groove between iliacus and psoas .In this

position, it passes behind the inguinal ligament to enter the thigh. Then, it

lies lateral to the femoral artery. After a short course it ends by dividing

into anterior and posterior divisions.

Muscular Branches

1. In the abdomen, it gives branches to the iliacus muscle.

2. Then little above inguinal ligament, the femoral nerve gives branch to

the nerve to the pectineus. The nerve passes downwards and medially

behind the femoral vessels to reach pectineus.

3. The anterior division of the femoral nerve supplies the sartorius

4. The posterior division supplies:

a. The rectus femoris c. The vastus medialis

b. The vastus lateralis d. The vastus intermedius

10

BRANCHES

11

CUTANEOUS BRANCHES

1. The anterior division gives the intermediate cutaneous nerve of the

thigh

a. Supplies a broad strip of skin on the front of thigh.

b. Lower end of front knee.

2. The anterior division also gives medial cutaneous nerve of the thigh

a. It lies along lateral side of the femoral artery which it crosses near

apex of the triangle.

b. It divides into branches and supplies the skin of the medial side of

the thigh.

c. The nerve takes part in subsartorial plexus (along with branches of

the saphenous and obturator nerves).

3. The posterior division gives saphenous nerve

a. Descends along the lateral of the femoral artery.

b. In adductor canal, the nerve crosses the artery from lateral side to

medial side of femoral artery.

c. It leaves hunter’s canal at its lower end and runs down along the

medial side of the lower knee. Here, it pierces deep fascia and becomes

subcutaneous.

d. Then runs down medial side of the leg along the long saphenous vein.

A branch extends with medial side of the foot but ends short of the great

toe.

e. The saphenous nerve takes part in subsartorial plexus and the patellar

plexus.

12

FEMORAL NERVE CUTANEOUS SUPPLY

13

Articular Branches

1. The posterior division of the femoral nerve sends fibres to the knee joint

through the nerve to the vastus medialis.

2. Some minor fibres reach the hip joint through the nerve to the rectus

femoris.

14

THE FASCIA ILIACA

It spans from lower thoracic vertebrae to the anterior thigh

It lines posterior abdomen and pelvis and covers iliacus and psoas

muscles

Forms posterior wall of femoral sheath and cover femoral vessels

It is covered by fascia lata in femoral triangle.

ATTACHMENTS:

Throcolumbar fascia attached laterally

Medially attached by vertebral column, pectineal fascia

Anteriorly by posterior part of inguinal ligament

NEUROVASCULAR RELATIONS

Femoral vessels lie superficial to the fascia iliaca above the inguinal

ligament. Behind inguinal ligament the area is divided into medial and

lateral parts.

Fascia iliaca forms the posterior wall of the femoral sheath medially

It forms the roof of the lacuna musculorum laterally, contains psoas

major, iliacus and femoral nerve

15

THE FASCIA ILIACA COMPARTMENT

It is a potential space

Anteriorly: Posterior surface of the fascia iliaca, which covers the

iliacus muscle, and the psoas major muscle.

Posteriorly: anterior surface of iliacus and psoas major.

Medially: vertebral column,

Cranio laterally- by the inner lip of iliac crest.

Cranio-medially – forms the space between quadratus lumborum and

its fascia.

Deposition of local anaesthetics of this compartment allows spread to

major nerves that supply the medial, anterior and lateral thigh

16

FASCIA ILIACA COMPARTMENT

17

LIGNOCAINE

Lignocaine an aminoethyl amide an amide group local anaesthetic.

Introduced in 1948

Most widely used local anaesthetic and also an antiarrhythmic agent.

Lidocaine produces faster, more intense, longer-lasting, and more

extensive anesthesia than does an equal concentration of procaine.

It blocks the nerve conduction by decreasing the entry of sodium

ions during the upstroke of action potential.

Once the concentration of local anesthetics increases the rate of rise

of action potential and the maximum depolarization decreases

causing slowing of conduction. Hence local depolarization doesn’t

reach the threshold potential and conduction block ensues.

Lidocaine is absorbed rapidly after parenteral administration and

from the GI and respiratory tracts.

Lidocaine is dealkylated in the liver by CYPs to monoethylglycine

xylidide and glycine xylidide, which can be metabolized further to

monoethylglycine and xylidide.

18

Both monoethylglycine xylidide and glycine xylidide retain local

anesthetic activity.

About 75% of the xylidide is excreted in the urine as the further

metabolite 4-hydroxy-2,6-dimethylaniline.

Duration of action after infiltration- 60-120 minutes

Maximum single dose for infiltration – 300mg

pKa- 7.9

Protein binding – 70%

Nonionized fraction at pH 7.4- 25%

Nonionized fraction at pH 7.6- 33%

Lipid solubility- 2.9, Volume of distribution- 91 liters (L)

Clearance – 0.95 L/min.

Elimination half time – 96 minutes

Effects of lignocaine.

19

BUPIVACAINE

Bupivacaine is an amide local anesthesia

Racemic preparation of R-bupivacaine and S-bupivacaine

S-bupivacaine is as potent as the racemic preparation but is less toxic

Long acting

Slow onset – 10-15 mins

17% Nonionized fraction at PH 7.4

24 % nonionized fraction at PH 7.6

Volume of distribution- 73 liters

Clearance – 0.47 L/min

Elimination half life time—210 minutes

Appropriate for procedures that last 2-2.5 hours

Available hyperbaric forms include concentrations of 0.5% and

0.75%, with dextrose 8.25%.

20

Isobaric formulations are available in concentrations of 0.5% and

0.75%.

When using isobaric solutions, the total mg dose is more important

than the total volume of medication administered.

Dose for lower limbs- 4-10mg

Dose for lower abdomen- 12-14 mg

Dose for upper abdomen- 12-18 mg

Addition of epinephrine to bupivacaine as addictive increases

duration by 50%

Addition of epinephrine increases the duration more in lumbosacral

than thoracic segments.

Metabolised by aromatic hydroxylation, N-dealkylation, amide

hydrolysis and conjugation.

N-dealkylated metabolite – N-desbutylbupivacaine is measured in

blood or urine after spinal or epidural anaesthesia

Alpha 1 acid glycoprotein is most important plasma protein binding

site.

Accidental injection of bupivacaine result in precipitous

hypotension, AV heart block, cardiac dysarrythmias.

21

After injection the protein binding sites are quickly saturated and

leaves unbound form more to diffuse into conducting system.

Premature ventricular contractions, widening of QRS complex and

ventricular tachycardia are common cardiac dysarrythmias.

Pregnancy may increase the sensitivity to cardiotoxic effects to

bupivacaine.

It intensifies and depresses electrical conduction causing reentrant

type ventricular dysarrythmias.

The addition of intrathecal fentanyl 5 mcg provides a bupivacaine

dose sparing effect similar to 15 or 20 mcg of IV fentanyl.

22

ULTRASONOGRAM

Ultrasound allows noninvasive visualization of tissue structures.

Ultrasound sound guided nerve block have become very popular and it is

essential in regional anaesthesia. In 1880, French physicists Pierre Curie

and Paul-Jacques Curie, discovered the piezoelectric effect, which can

generate and receive mechanical vibrations with high frequency. In 1978

P.La Grange and his colleagues published a case series report of ultrasound

application for peripheral nerve block. In 61 patients they performed

Supraclavicular brachial plexus block for which they used doppler

transducer to locate the subclavian artery. In 1989 Ting and

Sivagnarathnam used B mode ultrasound and demonstrated anatomy of

axilla and axillary brachial plexus block drug spread.

Ultrasound is high-frequency sound and refers to mechanical

vibrations above 20 kHz. Ultrasound frequencies commonly used for

medical diagnosis are between 2 and 15 MHz

The piezoelectric effect is an effect exhibited by the generation of an

electric charge in response to mechanical force applied on certain

materials. Mechanical deformation can be produced when an electric

field is applied to such material, also called the piezoelectric effect.

23

Quartz crystals, ceramic materials and Lead zirconate titanate are

materials that exhibit piezoelectric effect. Lead free piezoelectric

materials are under development.

PIEZOELECTRIC EFFECT

While passing through the tissue’s ultrasound wave comes across

various interactions like reflection, scattering and absorption.

Where there is a boundary between different media part of ultrasound

is reflected and the rest is transmitted. The reflection intensity is solely

dependent on the angle which means the transducer should be placed

perpendicular to the target nerve for clear visualization.

The coupling medium is necessary to displace the air from the

transducer and air interface. Gels and oils are used for this purpose they

act as lubricants providing a smooth surface scanning.

Scattering is redirection of ultrasound waves by rough surface or

heterogeneous media.

24

B MODE:

The primary mode used in regional anesthesia. It provides cross

sectional image for the area of interest. In this, there is simultaneous

scanning from a linear array of 100-300 piezoelectric crystals. The

amplitude of the echo is converted into dots of different brightness in B

scan. The echo strength is indicated by the gray scale intensity and real

distance in tissues is represented by horizontal and vertical distances.

B MODE TRANSDUCER

DOPPLER MODE- to detect the presence and nature of blood vessels.

In regional anaesthesia two types of transducers are used- Linear and

curvilinear transducers.

25

Linear Curvilinear

Rectangular Curvilinear in shape

Beam is rectangular, and the near-

field resolution

Convex beam and in-depth

examinations

2 to 16 MHz 2 to 7 MHz

Linear and Curvilinear Probe

26

The peripheral nerves are in close vicinity to the vessels or between

the muscle layers in general. The echo texture can be hyperechoic,

hypoechoic or honeycomb pattern. To facilitate adequate nerve imaging,

proper selection of sonographic modes, functional keys adjustment, needle

visualization and image artifact interpretation are the certain steps. For

peripheral nerve visualization three imaging modes are commonly used-

conventional imaging, compound imaging and tissue harmonic imaging

(THI).

For achieving an optimal image while performing peripheral nerve

imaging five functional keys on an ultrasound machine play vital role

1) Depth 2) Frequency 3) Focusing 4) Gain 5) Doppler

COMPOUND AND CONVENTIONAL IMAGING

27

With the relevance to needle -transducer relationship, two needle

insertion techniques are being used commonly.

In-plane technique: Needle is placed in the plane of ultrasound beam.

Hence the needle shaft and tip can be observed in the longitudinal view

when it is advanced towards the target structure. One should stop

advancing the needle when the needle visualization fails. Tilting or rotating

the transducer can help with visualization.

Out of plane technique: The needle is inserted perpendicular to the

transducer. The shaft of the needle is seen in the cross-sectional plane and

as a bright dot.

IN-PLANE AND OUT OF PLANE TECHNIQUE

28

OPERATIONAL SETUP

FIELD DEPTH

(CMS)

FREQUENCY

(MHZ)

PERIPHERAL BLOCKADES

< 2 12-15 Wrist, ankle block

2-3 10-12 Interscalene and axillary

3-4 10-12 Femoral, Supraclavicular and TAP

4-7 5-10 Infraclavicular, Popliteal and sub gluteal

sciatic nerve block

7-10 5-10 Pudendal, gluteal sciatic and lumbar

plexus block

>10 3-5 Anterior approach to sciatic nerve

IMAGING DEPTH AND FREQUENCY FOR COMMON

PERIPHERAL NERVE BLOCKS

29

FASCIA ILIACA COMPARTMENT BLOCK

INDICATIONS

To reduce the requirement for systemic analgesics such as opioids

and NSAID’s and avoid their side effects.

Pre-op analgesia for patients with neck of femur or femoral shaft

fractures.

Analgesia for the application of POP in children with femoral

fractures

Analgesia for AK amputation

Analgesia for knee surgeries

CONTRA-INDICATIONS

Patient refusal

Allergy or previous anaphylactic reaction to local anaesthetic.

Inflammation or infection over the site of injection.

Previous femoral-bypass surgery, or near a graft site.

Abnormal coagulation studies.

Complications:

Intravascular injection

Block failure

Nerve damage

Infection

30

Ultrasound Technique

The ultrasound-guided technique is essentially the same.

Monitoring of the needle placement and local anesthetic delivery

assures deposition of the local anesthetic into the correct plane.

• Transducer position: transverse, close to the femoral crease and lateral to

the femoral artery.

• Goal: medial–lateral spread of local anesthetic underneath the fascia

iliaca

• Local anesthetic: 20ml of lignocaine 2% with adrenaline 5mcg/ml

Identifying the femoral artery at the level of the inguinal crease. If it is

not immediately visible, sliding the transducer medially and laterally

will eventually bring the vessel into view.

Immediately lateral and deep to the femoral artery and vein is a large

hypoechoic structure, the iliopsoas muscle It is covered by a

31

hyperechoic fascia, which can be seen separating the muscle from the

subcutaneous tissue superficial to it.

The hyperechoic femoral nerve should be seen wedged between the

iliopsoas muscle and the fascia iliaca, lateral to the femoral artery.

The fascia lata (superficial in the subcutaneous layer) is more superficial

and may have more than one layer.

Moving the transducer laterally several centimeters brings into view the

sartorius muscle covered by its own fascia as well as the fascia iliaca.

Further lateral movement of the transducer reveals the anterior superior

iliac spine.

Equipments required:

The equipment needed for a fascia iliaca block includes the following:

Ultrasound machine with linear transducer (6–14 MHz), sterile

sleeve, and gel

Standard nerve block tray.

20-mL syringes containing local anesthetic

80- to 100-mm, 22-gauge needle

32

PATIENT POSITIONING AND LANDMARKS

This block is typically performed with the patient in the supine position,

with the bed or table flattened to maximize access to the inguinal area.

Although palpation of a femoral pulse is a useful landmark, it is not

required because the artery is quickly visualized by placement of the

transducer transversely on the inguinal crease, followed by slow

movement laterally or medially.

Tilting the probe while pressing helps to identify the hyperchoic fascia

iliaca superficial to the hypoechoic iliopsoas muscle.

Medially, the Femoral nerve is visualized deep to the fascia and lateral

to the artery Laterally, the sartorious muscle is identified by its typical

triangular shape when compressed by the transducer.

33

34

TECHNIQUE

With the patient in the proper position, the skin is disinfected and

the transducer positioned to identify the femoral artery and the iliopsoas

muscle and fascia iliaca. The transducer is moved laterally until the

sartorius muscle is identified. After a skin wheal is made, the needle is

inserted in plane.

As the needle passes through fascia iliaca, the fascia is first seen

indented by the needle. As the needle eventually pierces the fascia, a “pop”

may be felt, and the fascia may be seen to “snap” back on the US image.

After negative aspiration, 1–2 mL of local anesthetic is injected to confirm

the proper injection plane between the fascia and the iliopsoas muscle .

If local anesthetic spread occurs above the fascia or within

thesubstance of the muscle itself, additional needle repositions

andinjections may be necessary. A proper injection will result in

theseparation of the fascia iliaca by the local anesthetic in themedial–lateral

direction from the point of injection as described.

Releasing the pressure of the transducer may reduce the resistance

to injection and improve the distribution of local anesthetic. In an adult

patient, 20 mL of local anesthetic is usually required for successful

blockade. In children, 0.7 mL/kg is commonly used. The success of the

block is best predicted by documenting the spread of local anesthetic

35

toward the femoral nerve medially and underneath the sartorius muscle

laterally.

In obese patients, an out-of-plane technique may be favored. An

alternative suprainguinal technique may result in a more proximal spread

and possibly more efficacious analgesia after hip surgery.

36

FEMORAL NERVE BLOCK

Advantages:

Suitable for post op analgesia

When unilateral block is desired.

Disadvantages:

Unpredictable success rate

Longer onset time

Increased likelihood of systemic toxicity

INDICATIONS:

Analgesia for positioning of patient in femur fracture

Outpatient procedures

Post op pain care in fracture femur neck, shaft of femur fracture,

patellar fractures

Early mobilization after THR/TKR

CRPS type 1 and 2

Post amputation pain

Polyneuropathy

Arthritis

37

CONTRAINDICATIONS:

Infection or inflammation at the site of injection

Hematoma at the site

Abnormal coagulation studies

Hemorrhagic diathesis

Patients with femoral bypass

Local nerve injury

POSITIONING:

Supine

LANDMARK TECHNIQUE

The femoral artery is palpated 1 to 2 cms distal to inguinal ligament,

held between index and middle finger

Injection point lies 1-1.5 cm laterally

Then give 20ml of Inj.Lignocaine 2% with intermittent aspiration

38

CONTRAINDICATIONS:

Infection or inflammation at the site of injection

Hematoma at the site

Abnormal coagulation studies

Hemorrhagic diathesis

Patients with femoral bypass

Local nerve injury

ULTRASOUND TECHNIQUE

• Transducer position: transverse, femoral crease

• Goal: local anesthetic spread adjacent to the femoral nerve

• Local anesthetic: 10–15 mL

39

ULTRASOUND ANATOMY

Orientation begins with the identification of the femoral artery at the

level of the femoral crease. Commonly, the femoral artery and the deep

artery of the thigh are both seen. In this case, the transducer should be

moved proximal until only the femoral artery is seen .The femoral nerve is

lateral to the vessel and covered by the fascia iliaca; it is typically

hyperechoic and roughly triangular or oval in shape. Femoral nerve

typically is visualized at a depth of 2-4cm.

DISTRIBUTION OF ANESTHESIA

Femoral nerve block results in anesthesia of the anterior and medial

thigh down to and including the knee, as well as a variable strip of skin on

the medial leg and foot. It also innervates the hip, knee, and ankle joints.

EQUIPMENT

The equipment recommended for a femoral nerve block includes the

following:

• Ultrasound machine with linear transducer (8–18 MHz), sterile sleeve,

and gel

• Standard nerve block tray

• One 20-mL syringe containing local anesthetic

• A 50- to 100-mm, 22-gauge, needle

• Sterile gloves

40

PATIENT POSITIONING AND LANDMARKS

This block typically is performed with the patient in the supine position,

with the bed or table flattened to maximize operator access to the inguinal

area. The transducer is placed transversely on the femoral crease, over the

pulse of the femoral artery, and moved slowly in a lateral-to-medial

direction to identify the artery.

TECHNIQUE

With the patient in the supine position, the skin over the femoral

crease is disinfected and the transducer is positioned to identify the femoral

artery and nerve. If the nerve is not immediately apparent lateral to the

artery, tilting the transducer proximally or distally often helps to image and

highlight the nerve from the iliacus muscle and the more superficial

adipose tissue. In doing so, an effort should be made to identify the iliacus

muscle and its fascia, as well as the fascia lata, because injection

underneath a wrong fascial sheath may result in block failure.

Once the femoral nerve is identified, a skin wheal of local anesthetic

is made 1 cm away from the lateral edge of the transducer. The needle is

inserted in plane in a lateral-to medial orientation and advanced toward the

femoral nerve.

In addition, a needle passage through the fascia iliaca is often felt.

Once the needle tip is adjacent (either above, below, or lateral) to the nerve

41

.and after careful aspiration, 1–2 mL of local anesthetic is injected to

confirm proper needle placement .Proper injection will push the femoral

nerve away from the injection.

Additional needle repositions and injections are done only when

necessary. In an adult patient,20ml of local anesthetic is adequate for a

successful block.

42

SPINAL ANAESTHESIA

Spinal anesthesia involves use of small amounts of local anesthetic

injected into subarachnoid space to produce a reversible loss of sensation

and motor function. The anesthesia provider places the needle below L2 in

the adult patient to avoid trauma to the spinal cord. Spinal anesthesia

provides excellent operating conditions for:

Advantages of Spinal Anesthesia

Easy to perform

Reliable

Provides excellent operating conditions for the surgeon

Less costly than general anesthesia

Normal gastrointestinal function returns faster with spinal anesthesia

compared to general anesthesia

Patient maintains a patent airway

A decrease in pulmonary complications compared to general

anesthesia

43

Decreased incidence of deep vein thrombosis and pulmonary emboli

formation compared to general anesthesia

Disadvantages of Spinal Anesthesia

Risk of failure even in skilled hands. Always be prepared to induce

general anesthesia.

Normal alteration in the patient’s hemodynamics. It is essential to

place the spinal block in the operating room, while monitoring the

patient’s ECG, blood pressure, and pulse oximetry. Resuscitation

medications should be available.

The operation could outlast the spinal anesthetic. Alternative plans

(i.e. general anesthesia) should be prepared in advance

Mechanism of Action

Local anesthetics administered in subarachnoid space block sensory,

autonomic, and motor impulses as the anterior and posterior nerve roots

pass through the CSF. The site of action includes spinal nerve roots and

dorsal root ganglion

Technique

The technique of administering spinal anesthesia can be described :

preparation, position, projection, and puncture

44

Preparation

Discuss with the patient options for anesthesia. Explain risk and

benefits. Inform the patient about the following: despite sedation

patient may remember portions of the surgical procedure but

shouldn’t feel discomfort, the patient may feel pressure sensations

but no pain, the patient will not be able to move their legs

Choose an appropriate local anesthetic..

Choose the appropriate spinal needle. Spinal needles are available in

a variety of sizes (from 16-30 gauge), lengths, bevel types, and tip

designs. A 25-27 gauge needle is commonly used in patients that are

less than 50 years of age. A smaller needle is used in the younger

patient to decrease post dural puncture headache. Needles are cutting

or blunt tiped. The Quincke needle is a cutting needle, with the

opening at end of the needle

Blunt tipped needles (pencil point) decrease the postdural puncture

headaches compared to cutting needles. Whitacre and other pencil point

needles, have a rounded tip with a side port. Sprotte needles have a long

opening, allowing excellent CSF flow.

Positioning

There are 3 positions used for the administration of spinal

anesthesia: lateral decubitus, sitting, and prone

45

Lateral Decubitus

Allows the anesthesia provider to administer more sedation- less

dependence on an assistant for positioning. (Never over sedate a

patient).

The patient is positioned with their back parallel with the side of the

operation table. Thighs are flexed up, and the neck is flexed forward

(fetal position).

Patient should be positioned to take advantage of the baricity of the

local anesthetic

Sitting

Used for anesthesia of the lumbar and sacral levels.

Identify anatomical landmarks. This may be a challenge in the obese

or those with abnormal anatomical curvatures of the spine. Place the

patient feet on a stool, have the patient sit up straight, head flexed,

arms hugging a pillow. Make sure the patient does not simply lean

forward.

46

For a lower lumbar/sacral block (i.e. saddle block), leave the patient

sitting for 15 minutes before assuming a supine position

Prone

The prone position is used when the patient will be in this position

for the surgical procedure like rectal, perineal and lumbar surgeries.

Hypobaric local anesthetics are usually administered Patient

positions self, lumbar lordosis should be minimized, paramedian

approach is often used.

Projection and Puncture

There are two approaches to access the subarachnoid space:

paramedian and midline approach.

47

Midline Approach

The midline approach affords the practitioner two advantages.

Anatomic projection is only in 2 planes, making visualization of the

intended trajectory and anatomical structures more apparent. The midline

provides a relatively avascular plane.

“Tuffier’s” line is a line drawn across the iliac crest that crosses the

body of L4 or L4-L5 interspace. This is a helpful landmark for the

placement of spinal or epidural anesthetics.

Paramedian Approach

The advantage of the paramedian approach is a larger target. By

placing the needle laterally, the anatomical limitation of the spinous

process is avoided. The most common error when attempting this

48

technique is being too far from the midline, which makes encountering the

vertebral lamina more likely.

Palpate the vertebral process and identify the caudad tip. Move 1 cm

down and 1 cm laterally.

49

REVIEW OF LITERATURE

1. The study titled “Ultrasound Guided Femoral Nerve Block to Provide

Analgesia for Positioning Patients with Femur Fracture Before

Subarachnoid Block: Comparison with Intravenous Fentanyl”

It is randomized trial done on Forty patients undergoing surgery for

femur fracture were randomized to either femoral nerve block (FNB) or

intravenous fentanyl (IVF) group. Group FNB (n=20) received 20 ml of

2% lignocaine around femoral nerve under ultrasound guidance. IVF group

(n=20) received 2 mc/kg of fentanyl intravenously. Pain score on effected

limb was assessed after five minutes. If VAS was ≤ 4, the patient was

positioned in sitting for subarachnoid block. On failure to achieve this with

the above treatment, intravenous fentanyl 0.5 mc/kg was administered and

repeated as necessary before positioning.

VAS during positioning was documented and compared between the

two groups. Similarly, secondary outcomes of the intervention: quality of

patient position, rescue analgesia and duration of the procedure were also

compared. Data were subjected to Mann Whitney U-test and chi-square

test. Level of significance was set at 0.05.Result: FNB group had

significantly less VAS scores (median) than IVF group :2 vs 3; p=0.037)

during positioning for spinal anaesthesia. Procedure time (median) for

spinal anaesthesia was also significantly less in FNB than in IVA group

(10 vs 12 min; p=0.033) Ultrasound guided femoral nerve block was

50

more effective than intravenous fentanyl for reducing pain in patients

with proximal femur fracture before spinal anaesthesia.

2. The study titled “Analgesia before a spinal block for femoral neck

fracture: fascia iliaca compartment block”

In this study the 40 patients were randomly assigned to one of two

groups, namely, the FIC group (fascia iliaca compartment block, n520) and

the IVA group (intravenous analgesiawith alfentanil, n520). Group IVA

patients received a bolus dose of i.v. alfentanil 10mg/kg, followed by a

continuous infusion of alfentanil 0.25mg/kg/min starting 2 min before the

spinal block, and group FIC patients received a FIC block with 30 ml of

ropivacaine 3.75 mg/ml (112.5 mg) 20 min before the spinal block. Visual

analogue pain scale (VAS) scores,time to achieve spinal anaesthesia,

quality of patient positioning, and patient acceptance were compared.

Results: VAS scores during positioning (mean and range) were lower in

the FIC group than in the IVA group [2.0 (1–4) vs. 3.5 (2–6), P50.001],

and the mean (_ SD) time to achieve spinal anaesthesia was shorter in the

FIC group (6.9 _ 2.7min vs. 10.8 _ 5.6min; P50.009). Patient acceptance

(yes/no) was also better in the FIC group (19/1) than in the IVA group

(12/8)(P50.008).they concluded that an FIC block is more efficacious

than i.v.alfentanil in terms of facilitating the lateral position for spinal

anaesthesia in elderly patients undergoing surgery for femoral neck

fractures.

51

3. The study titled “Analgesia before Performing Subarachnoid

Block in the Sitting Position in Patients with Proximal Femoral

Fracture: A Comparison between Fascia Iliaca Block and Femoral

Nerve Block”

In this study, Group FICB patients (n=15) received fascia iliaca block

with 30 ml of 1.5% lignocaine with adrenaline and group FNB patients

(n=15) received femoral nerve block with 15 ml of 1.5% lignocaine with

adrenaline. After the study blocks, patients were kept on supine position

for at least 20 minutes before shifting them to the operation theatre. Pain

was assessed by using visual analog scale values before the block and

during the position for subarachnoid block. Time to perform subarachnoid

block, quality of positioning and acceptance was recorded.

Visual analog scale values during positioning for SAB were lower

in FIB group than in FNB (1.0±1.1 versus 2.1±0.8; P<0.05). Time to

perform SAB was shorter in FIB than in FNB (109.6±28.2 seconds vers us

134.8±31.9 seconds; P<0.05). Quality of patient positioning for SAB was

comparable between the groups. Patient acceptance was less in group FNB

(P<0.05).

They concluded that Fascia iliaca compartment block provides

better analgesia than femoral nerve block in terms of facilitating

optimal positioning for subarachnoid block in patients undergoing

proximal femoral fracture fixation procedure

52

4. The study titled “ULTRASOUND-GUIDED CONTINUOUS

FEMORAL NERVE BLOCK VS CONTINUOUS FASCIA

ILIACA COMPARTMENT BLOCK FOR HIP REPLACEMENT IN

THE ELDERLY”: A RANDOMIZED CONTROLLED CLINICAL

TRIAL.

Department of Anesthesiology, Tongji Hospital of Tongji

University, Shanghai, China.

In this prospective, randomized controlled clinical investigation, 60

elderly patients undergoing hip replacement were randomly assigned to

receive either continuous femoral nerve block or

continuous fascia iliaca compartment block. After ultrasound-guided

nerve block, all patients received spinal anesthesia for surgery and

postoperative analgesia through an indwelling cannula.

There was a significant difference between the 2 groups in the mean

visual analog scale scores (at rest) at 6 hours after surgery: 1.0 ± 1.3 in

the femoral nerve block group vs 0.5 ± 0.8 in

the fascia iliaca compartment block group (P < 0.05). The femoral

nerve block group had better postoperative analgesia on the medial aspect

of the thigh, whereas the fascia iliaca compartment block group had better

analgesia on the lateral aspect of the thigh. There were no other significant

differences between the groups.they concluded that on Both ultrasound-

guided continuous femoral nerve block and fascia iliaca compartment

53

block with the novel cannula-over-needle provide effective anesthesia and

postoperative analgesia for elderly hip replacement patients.

5. The study titled A Randomized Study to Compare the Analgesic

Efficacy of Ultrasound-Guided Block of Fascia Iliaca Compartment

or Femoral Nerve After Patella Fracture Surgery.

Department of Anesthesia, Jiangyin Hospital, Medical College of

Southeast University, No. 163, Shoushan Rd, Jiangyin, 214400, China.

The aim of this study was to compare the analgesic efficacy of the

ultrasound-guided block of femoral nerve or fascia iliaca compartment in

patients who underwent patella fracture surgery. Fifty patients were

blinded and randomized into groups treated with continuous

fascia iliaca compartment block (CFICB) (n = 25) or continuous femoral

nerve block (CFNB) (n = 25) after patella fracture surgery. Analgesic

effects of the two methods were assessed and compared. Patients from the

two groups showed no significant difference in visible analog scales at rest

and during movement, fentanyl consumption, nausea, and vomiting. The

time of catheter insertion was significantly shorter in carrying out CFICB

compared to that in performing CFNB (8.3 ± 1.4 vs 14.5 ± 3.0 min). Three

of the 25 patients in CFNB group experienced dysesthesia of anterior of

the thigh, a complication which was not observed in CFICB-treated

patients. CFICB and CFNB were equally effective in relieving pain after

54

the patella fracture surgery. However, compared to CFNB, CFICB was

found to be safer and easier to perform.

6. Iliac Fascia Compartment Block and Analgesic Consumption in

Patients Operated on for Hip Fracture.

patients undergoing surgical treatment of proximal femur fractures was

performed. Group 1 (n=35)consisted of patients who were treated with

pharmacologic analgesia only (systemic analgesics) and Group 2 (n=43)

involved patients who received a preoperative fascia iliaca compartment

block (FICB) and pharmacologic analgesia. FICB was per-formed under

ultrasound guidance, and systemic analgesics were administered according

to a standardized pro-to-col. Demographics, anesthesia and operation data

as well as the dosage of analgesics used on postoperative day 0 were

collected for the study.Patients with antecedent iliac fascia blockade

required fewer analgesic interventions (3 vs. 11, p <0.0001) and showed

significantly less need for analgesics than non-block patients. No

complications were observed after performing FICB. They concluded that

The iliac fascia compartment block produces effective postoperative

analgesia and reduces postoperative opioid consumption.

7. A comparison of two approaches to ultrasound-guided fascia iliaca

compartment block for analgesia after total hip arthroplasty.

55

Before induction of general anethesia, ultrasound-guided FICB were

administered. According to probe parallel to the inguinal ligament or

perpendicular to the inguinal ligament, patients were randomly divided into

the Parallel group and the Perpendicular group. Both groups was

administered an equal volume mixture of 1% ropivacaine and 1%

lidocaine, 30 ml in total. All patients received sufentanil postoperative

intravenous analgesia after surgery. Time to ultrasonic imaging, time to

perform the block and total blocking time were recorded. Loss of sensation

in the distribution areas of the femoral nerve and

lateral femoral cutaneous nerve within 30 mins were recorded. Patients

were interviewed at 4, 8, 12, 24, 36, 48 h after block for pain intensity, time

of first using PCA, sufentanil consumption and loss of skin sensation due

to the block. The occurrence of adverse events (nausea, vomiting,

respiratory inhibition, pruritus or urinary retention) was also recorded.they

concluded that Comparing the two approaches to ultrasound-guided FICB,

ultrasonic probe perpendicular to the inguinal ligament may offer better

blocking effect of lateral cutaneous nerve and reduce postoperative

sufentanil consumption, and might be more suitable for analgesic after

THA.

8 .The study titled “ Fascia iliaca block vs intravenous fentanyl as

ananalgesic technique before positioning for spinal anesthesia in

patients undergoing surgery for femur fractures”

56

Department of Anesthesiology, MS Ramaiah Medical College and

Hospitals, Bangalore, India

It is a randomized controlled trial done on Sixty patients aged 25 to

75 years, with ASA statusI to III, undergoing surgery for femur

fracturewere chosen for the study and randomized into 2 groups. Patients

in groupFICB received the block with 30 mL of 0.375% ropivacaine 15

minutes before the subarachnoid block. Patients in group IVF received

intravenous fentanyl at 0.5 μg/kg body weight repeated up to a maximum

of 3 doses. Spinal was administered using 12 to 15mgof 0.5%hyperbaric

bupivacaine with glucose 80mg/mL in patients of both groups.

Measurements: Pre procedural and post procedural parameters such as

visual analog scale (VAS) scores, sitting angle, quality of positioning, and

time to perform the spinal were recorded. Patients were also assessed in

the first 24 hours for analgesic requests .

They concluded that Preprocedural VAS scores were similar in both

groups. The “VAS after” was 24.72 ± 15.70 mm in group FICB vs 61.22 ±

18.18 mm in group IVF (P = .01). The drop in VAS scores was

significantly more in the FICB group. Sitting angle improved

significantly in the FICB group.(56.17° ± 16.54° vs 21.38° ± 23.90°; P

= .01). Patients in group FICB also needed less time for spinal and had

better quality of positioning. Postoperative analgesic requirement was

lesser in group FICB.

57

AIM AND OBJECTIVES

Compare the feasibility and effectiveness of fascia iliaca block and

femoral nerve block in reducing pain associated with positioning for

subarachnoid block in patients undergoing proximal femour fixation

procedures.

PRIMARY OUTCOME

VAS score before and VAS score at positioning for SAB.

SECONDARY OUTCOME

Time to performance of Spinal block

Quality of positioning during spinal Anaesthesia

No of attempts

Hemodynamic variability

Failure to Perform Spinal Anaesthesia

58

MATERIALS AND METHODS

After obtaining informed and written consent from 60 ASA 1, 2 and

3 patients, who were scheduled for orthopedic surgeries (lower limb) in

Government Rajaji Hospital, Madurai were participated in this study.

Hospital ethical committee approval was obtained.

60 patients were randomized into 2 groups,

Group 1- FICB

Group 2- FEMORAL NERVE BLOCK

INCLUSION CRITERIA

ASA 1,2 and 3

Age-18 to 65 years

Both sexes

Proximal femour fixation surgery

EXCLUSION CRITERIA

ASA 4

Age <18 and >65

Allergic to local anaesthetics

Hepatic or renal failure

Coagulation abnormalities

Infection/Inflammation at the site of injection .

59

ANAESTHETIC TECHNIQUE

All the patients were premedicated with Inj.Midazolam 50mcg/kg

IM half an hour before surgery.

Preoperatively patient’s PR, BP, Spo2,RR and Visual analog scale

(VAS) for pain at Rest and movement were noted.

The patients were assessed for pain using a 10-point VAS before

performing block.

GROUP FICB:

o Receive usg guided fascia iliaca compartment block .

o They were given 1.5% inj.lignocaine 20 ml with inj.adrenaline

5mic/ml.

60

GROUP FNB:

o receive usg guided femoral nerve block.

o They were given 1.5% inj.lignocaine 20 ml with inj.adrenaline

5mic/ml

Techniques of block were described earlier in this chapter .

After performing the blocks the patients were kept in supine position

for at least 20 min .

The patients were made to sit with the help of operation theatre

assistants while the skeletal traction was maintained.

VAS was enquired and noted.

Once the patient was in sitting position SAB was administered and laid

down back to supine position.

Time required to perform SAB (as defined as time from insertion of

the spinal needle to complete deposit of drug in the subarachnoid space)

was noted.

quality of patient positioning

Positioning was subjectively rated as good or satisfacfactory depending

on the ease of positioning for SAB.

No of attempts

No of attempts for performance of spinal anaesthesia were calculated.

Hemodyamic Variability

Hemodyamic changes were noted

61

STATISTICAL ANALYSIS

Data were analysed using the SPSS 20 software.

The clinical profile of patients was analysed using chi-square test

for categorical data and Unpaired t-test for continuous data

p value less than 0.05 was considered statistically significant.

62

OBSERVATION

Age distribution

Age in years Group FNB Group FICB

< 40 3 2

41 - 50 9 7

51 - 60 12 14

> 60 6 7

Total 30 30

Mean 53.07 54.6

SD 8.65 8.11

t' value 0.708

p' value 0.482 Not significant

INFERENCE

Age of the patients were comparable between two groups.

3

9

12

6

2

7

14

7

0

2

4

6

8

10

12

14

16

< 40 41 - 50 51 - 60 > 60

PA

TIE

NT

S

AGE IN YEARS

AGE DISTRIBUTION -COMPARISON

Group FNB Group FICB

63

Gender distribution

INFERENCE

Gender data were comparable between the groups.

0

5

10

15

20

Male Female

18

12

18

12

PA

TIE

NT

S

GENDER

GENDER COMPARISON


Gender Group FNB Group FICB

Male 18 18

Female 12 12

Total 30 30

Chi square 0.069

p value 0.792 Not Significant

64

Weight distribution

Weight in kgs Group FNB Group FICB

< 50 2 5

51 - 56 17 8

61 - 70 10 16

> 70 1 1

Total 30 30

Mean 59.2 61.87

SD 7.14 8.44

t' value 1.32


INFERENCE

Weight of the patients were comparable between two groups.

0

5

10

15

20

< 50 51 - 56 61 - 70 > 70

2

17

10

1

5

8

16

1

PA

TIE

NT

S

Wt in Kgs

WEIGHT COMPARISON


65

Vas score at block

INFERENCE

VAS score at block were comparable between two groups.

0

10

20

30

2 3 4 5

1

1412

30

23

6

1PA

TIE

NT

S

VAS SCORE

VAS SCORE AT BLOCK


VAS at Block Group FNB Group FICB

Score 2 1 0

3 14 23

4 12 6

S 5 3 1

Total 30 30

Mean 3.57 3.27

SD 0.73 0.52

t' value 1.836


66

VAS AT POSITIONING FOR SAB

vas at positioning for

SAB Group FNB Group FICB

Score 0 0 1

1 1 20

2 16 9

S 3 13 0

Total 30 30

Mean 2.4 1.27

SD 0.57 0.52

t' value 8.09

p' value < 0.001 Significant

INFERENCE

VAS score at positioning for sab is better in FASCIA ILLIACA

COMPARTMENT BLOCK than FEMORAL NERVE BLOCK.

0

5

10

15

20

0 1 2 3

0 1

16

13

1

20

9

0

PA

TIE

NT

S

VAS SCORE

VAS AT POSITIONING FOR SAB


67

0

1

2

3


2.4

1.27

PA

TIE

NT

S

VAS SCORE

Mean VAS SCORE AT POSITIONING FOR SAB


68

Time to performing spinal anaesthesia

Time to perform SAB Group FNB Group FICB

< 120 9 25

121 - 140 13 5

> 140 8 0

Total 30 30

Mean 133 107.2

SD 15.45 11.08

t' value 7.431

p' value < 0.001 Significant

INFERENCE

Time required for performing the SAB is much lower in FICB than

FNB group Better pain relief and, therefore, better positioning with

the FICB group.

0

50

100

150


133107.2

PA

TIE

NT

S

TIME in Sec

Mean TIME TO PERFORM SAB


69

Quality of positioning

Quality Group FNB Group FICB

Good 21 28

Unsatisfactory 9 2

Total 30 30

Chi square 4.007

p value 0.045 Significant

INFERENCE

Good analgesia and paralysis of some muscles (eg. quadriceps)

following FICB are the likely reasons for more comfortable positioning in

the group.

0

10

20

30

Good Unsatisfactory

21

9

28

2PA

TIE

NT

S

SATISFACTION SCORE

QUALITY COMPARISON


70

NO OF ATTEMPTS COMPARISON

PATIENTS

No of attempts

INFERENCE:

FICB has made spinal anaesthesia position easier compared to femoral

nerve block. 30 patients out 30 were shown successful single attempt for

spinal anaesthesia in FICB group and only 22 patients out of 30 in FNB

group.

0

5

10

15

20

25

30

group fnb gp ficb

one attempt

more than one attempts

NO OF ATTEMPTS Group FNB Group FICB

One attempt 22 30

More than one attempts 8

0

Total 30 30

P value <0.005

71

HEMODYNAMIC VARIABILITY

SYSTOLIC BLOOD PRESSURE DURING POSINING OF SPINAL

ANAESTHESIA

100

105

110

115

120

125

130

135

baseline 1min 2min 3min 4 min 5 min 6 min

Group FNB

Group FICB

72

DIASTOLIC BLOOD PRESSURE DURING POSITIONING FOR

SPINAL ANAESTHESIA

0

20

40

60

80

100

120

baseline 1min 2min 3min 4min 5min 6min

Group FNB

Group FICB

73

PULSE RATE VARIABILITY DURING POSITIONING OF

SPINAL ANAESTHESIA

0

20

40

60

80

100

120

Baseline 0 min 1 min 2 min 3 min 4 min 5 min

Group FNB

Group FICB

74

RESULTS

The two groups were similar in terms of Age, Sex, Weight and

preoperative VAS both at rest and during movement. Baseline VAS scores

at the time of block were comparable between the groups.

Mean VAS score at positioning for SAB was signifiantly lower in

group FICB than in group FNB. Performance time for SAB in group FICB

was significantly shorter than FNB.

Performer rated quality of positioning was significantly better in

group FICB than group FNB. Patients acceptance was better in group FICB

than in group FNB. Rescue analgesia was required in two patients, one

from each group.

No of attempts for performing spinal anaesthesia was significantly

lower in FICB group than FNB group. No adverse systemic toxicity of

lignocaine was noted.

No complications such as hematoma or persistent paresthesia were

observed in patients with both the techniques of blocks within following

24 hours after the operation.

75

DISCUSSION

Positioning patients for spinal anesthesia with fractured femur is

challenging because even minimal overriding of the fracture ends is

exceedingly painful.

Providing analgesia before positioning not only increases patient

comfort but also improves positioning and successful spinal block

Fascia illiaca block offers superior analgesia compared to femoral nerve

block in patients with femur fracture during positioning for spinal

anaesthesia.

Visual analog scale during positioning of spinal anaesthesia Both

techniques provided reduction in VAS during positioning but

Reduction in VAS by FICB was higher than FNB in the present study

with higher significance.

VAS score 2.4 ±0.57 in FNB group were only 1.27 ±0.57 in FICB

group The obturator and lateral cutaneous nerve of thigh are not

affected by the FNB, explaining less reduction in pain in the group

This is in agreement with the study done by Dalen et al and Capdevila

et al.

76

TIME FOR PERFORMANCE OF SAB

Time required for performing SAB with FICB was almost half a

minute less than that of FNB in the present study. Better pain relief and,

therefore, better positioning with the FICB is well reflected in the time

required for performing the SAB.

Time required for performing SAB with FNB group is 133± 15.45

sec where as in FICB it is only 107±11.08 sec. Time required for

performing SAB were comparable between two groups. This is in

agreement with the study done by time reported by Sia et al.

Quality of positioning

Good analgesia and additional involvement of obturator nerve ana

lateral cutaneous nerve of thigh following FICB are the likely reasons for

more comfortable positioning in the group.

28 patients out 30 were shown good satisfaction with positioning and only

21 patients in group FNB shown good satisfaction with positioning.

No of attempts

Due to optimal positioning for SAB all the patients in group FICB-

are able to perform spinal within one attempt, but in group FNB only in 22

patients spinal performed within one attempts, remaining patients

successful in subsequent attempts.

77

Failure to give spinal anaesthesia

There was no failure in performing spinal anaesthesia in both

groups.

Complication

There was no failed block or patchy block noted.

There was no complications like giddiness,sweating while performing

spinal anaesthesia.

The results obtained by previous study regarding VAS score during

positioning for spinal anaesthesia ,time to perform spinal anaesthesia , and

patient satisfaction, no of attempts were similar to our study

78

CONCLUSION

Study demonstrate that fascia iliaca compartment block provides

better analgesia than femoral nerve block in terms of facilitating

optimal positioning for subarachnoid block in patients undergoing

proximal femoral fracture fixation procedure.

Being done under ultrasound guidance the risk of complications are

minimal.

79

BIBILOGRAPHY

1. Morau D, Lopez S, Biboulet P, Bernard N, Amar J, Capdevila X.

Comparison of continuous 3-in-1 and fascia iliaca compartment blocks

for postoperative analgesia: feasibility, catheter migration, distribution

of sensory block, and analgesic efficacy. Reg Anesth Pain Med 2003;28

(4): 309-14.

2. Capdevila X, Biboulet P,Bouregba M, Barthelet Y, Rubenovitch J,

d’Athis F. Comparison of three-in-one and fascia iliaca compartment

blocks in adults: clinical and radiographic analysis. Anesth Analg 1998;

86 (5): 1039-44

3. Dalens B, Vanneuville G, Tanguy A. Comparison of fascia iliaca

compartment block with 3-in-1block in children. Anesth Analg 1989;

69 (6): 705-13.

4. Monzon DG, Iserson KV, Vazquez JA. Single fascia iliaca

compartment block for post-hip fracture pain relief. J Emerg Med.

2007; 32 (3): 257-62.

5. Beaudoin FL, Nagdev A, Merchant R, Becker B. Ultrasound guided

femoral nerve blocks in elderly patients with hip fracture. American

journal of emergency medicine 2010; 28, 76-81.

80

6. Candal-Couto JJ, Mc Vie JL, Haslam N, Innes AR, Rushmer J. Pre-

operative analgesia for patients with femoral neck fractures using a

modified fascia iliaca block technique. Injury. 2005; 36 (4): 505-10.

7. Haines L, Dickman E, Ayvazyan S, Wu S, Rosenblum D, Likourezos

A. Ultrasound guided fascia iliaca compartment block for hip fractures

in the emergency department. J Emerg Med. 2012; 43(4): 692-7.

8. Sia S, Pelusio F, Barbagli R, Rivituso C. Analgesia before performing

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9. . Yun MJ, Kim YH, Han MK, Kim JH, Hwang JW, Do SH. Analgesia

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81

PROFORMA

NAME : I.P.NO: ASA:

AGE & SEX: WEIGHT :

DATE& TIME OF ADMISSION:

DATE& TIME OF DISCHARGE:

DIAGNOSIS:

PROCEDURE:

HISTORY: allergy to drugs ,uncontrolled hypertension, diabetes

mellitus, pulmonary pathology - asthma , COPD, h/o intake of beta

blockers, calcium channel blockers, long time opioid/NSAID intake, H/o

any other cardiac or respiratory medications

CLINICAL EXAMINATION: PR,BP, SPO2, RS, CVS.

BASIC INVESTIGATIONS:

Haemoglobin,

Random Blood Glucose

Renal Parameters & Serum Electrolytes,

Liver Parameters

ANAESTHETIC TECHNIQUE: Cases posted for proximal femour

fracture fixation surgery under subarachnoid block

They were randomly divided into two groups using sealed envelope

techniques:

82

GROUP FICB: group FICB to receive fascia iliaca compartment block.

GROUP FNB: group FNB to receive femoral nerve block.

Complications IF Any:

MONITORING OF VITALS:

PARAMETERS TO BE MONITORED:

1. VAS during block,

2. VAS at positioning for spinal anaesthesia,

3. Time to perform subarachnoid block,

4. Quality of patient positioning,

5. No of attempts,

6. Hemodynamic variability

7. Failure to perform spinal anaesthesia,

83

QUESTIONAIRRES USED IN THE STUDY

1) H/O Any Known allergy to any drugs

2) H/O Any systemic illness-Hypertension, Diabetes Mellitus, Bronchial

Asthma, Seizuredisorder, Pulmonary Tuberculosis, Peripheral vascular

disease

3) H/O of smoking ,COPD, Exertional dyspnoea,

4) H/O any cardiac or respiratory medications.

( Complaints related to CVS,RS, RENAL system)

84

GROUP FNB

S.NO. NAME AGE SEX WEIGHT

1 Pandiyan 60 M 58

2 Devi 38 F 62

3 Parameshwari 42 F 65

4 Bharathi 33 F 59

5 Jeyalaksmi 65 F 49

6 Arumugam 48 M 52

7 Parthiban 49 M 53

8 periyakka 46 F 58

9 Ganesan 57 M 56

10 Varathan 60 M 58

11 Ganthasamy 62 M 62

12 Kannayiram 68 M 58

13 Muthu 52 M 59

14 Petchi 54 F 64

15 Pothumponnu 55 F 52

16 Velu 49 M 53

17 Rakku 48 F 56

18 Santhanam 52 M 60

19 Sakkarai 53 M 63

20 kalyanamoorthi 56 M 62

21 Muthusamy 55 M 45

22 Pandiyaram 60 M 55

23 Ponnuselvam 62 M 60

24 Ilangovan 49 M 55

25 Annapoorani 64 F 62

26 Manikandan 48 M 70

27 Sasikala 40 F 85

28 Rani 44 F 58

29 Chellammal 65 F 65

30 Pooja 58 F 62

85

PR SPO2 SBP DBP vas at

block

vas at

positioning

for SAB

time to

perform

SAB

quality of

positioning

no of

attempts

92 98 140 70 4 3 136 1 1

100 99 120 80 4 2 117 1 1

80 98 130 80 4 3 130 1 1

82 99 120 80 5 3 162 0 3

86 97 140 80 3 2 124 1 1

89 98 130 90 3 2 136 1 1

94 99 100 70 4 3 141 0 1

96 98 110 80 4 3 152 0 2

83 99 100 80 3 2 112 1 1

84 97 130 70 5 3 159 0 2

85 98 140 90 4 3 144 0 2

87 99 120 80 4 3 150 0 2

84 98 130 90 4 2 124 1 1

83 99 140 90 3 2 136 1 1

92 99 120 80 3 2 109 1 1

77 98 110 80 3 2 139 1 1

79 99 110 80 2 1 104 1 1

85 100 130 90 3 2 119 1 1

87 99 130 80 4 3 133 1 1

89 97 110 70 4 3 160 0 3

77 99 140 80 3 2 120 1 1

80 98 130 80 3 2 137 1 1

100 97 150 80 4 3 140 0 2

89 99 110 80 3 2 130 1 1

90 98 130 80 3 2 139 1 1

85 97 120 80 3 2 120 1 1

79 98 110 70 4 3 135 1 1

92 99 110 90 5 3 149 0 2

95 97 140 80 3 2 117 1 1

82 100 130 70 3 2 115 1 1

86

GROUP FICB

S.NO. NAME AGE SEX WEIGHT

1 Palani 60 M 75

2 Palsamy 49 M 60

3 Palaniyammal 51 F 50

4 Periyya 54 M 59

5 amuthan 52 M 52

6 karthick 39 M 68

7 shanthi 66 F 63

8 chitra 59 F 65

9 madasamy 63 M 79

10 benazir 56 F 72

11 booma 47 F 65

12 karna 60 M 60

13 manikkam 45 M 53

14 nagarajan 50 M 60

15 kanthaiah 52 M 62

16 ganesan 54 M 55

17 gunasekaran 66 M 58

18 malarkodi 68 F 54

19 dhanam 63 F 50

20 poonkodi 49 F 63

21 muthammal 60 F 50

22 rakku 52 F 55

23 mugavar 70 M 57

24 ganesan 51 F 58

25 arasi 42 F 60

26 tamil 62 M 72

27 karuppaiah 55 M 75

28 madasamy 40 M 80

29 mokkan 49 M 64

30 chellappa 54 M 62

87

PR SPO2 SBP DBP vas at

block

vas at

positioning

for SAB

time to

perform

SAB

quality of

positioning

no of

attem

pts

100 99 140 90 4 2 120 1 1

88 98 140 70 3 1 110 1 1

78 99 120 80 3 1 92 1 1

80 99 130 90 3 1 100 1 1

82 98 130 90 3 1 90 1 1

84 99 110 70 3 1 100 1 1

86 97 140 80 3 1 102 1 1

88 98 120 90 3 1 100 1 1

92 99 130 90 4 2 122 1 1

80 98 130 90 3 2 121 1 1

88 99 120 90 3 2 117 1 1

90 98 130 80 3 1 100 1 1

82 99 110 70 3 1 102 1 1

92 97 120 80 3 1 103 1 1

86 99 120 80 4 2 115 1 1

88 100 130 90 3 1 105 1 1

96 99 130 90 5 2 125 0 1

77 99 140 90 3 1 97 1 1

76 97 130 80 3 1 90 1 1

100 98 110 70 4 2 123 1 1

88 99 140 80 3 1 100 1 1

82 97 130 80 3 1 102 1 1

77 99 150 90 3 1 115 1 1

84 98 140 70 3 1 108 1 1

86 97 120 90 3 1 104 1 1

88 98 130 80 3 0 90 1 1

99 100 120 90 4 2 120 1 1

105 99 120 70 4 2 127 0 1

92 99 130 90 3 1 105 1 1

90 98 140 80 3 1 110 1 1

88

INFORMED CONSENT FORM

1. I confirm that I have read and understood the information letter for the above

study and have had the opportunity to clear doubts.

2. I understand that my participation in the study is voluntary and that I’m free

to withdraw at any time, without giving any reason, without my medical care

or legal rights being affected.

3. I understand that the ethics committee and the regulatory authorities will not

need my permission to look at my health records both in respect of the current

study and any further research that may be conducted in relation to it even if

I withdraw from the trial. I agree to this access. However I understand that

my identity will not be revealed in any information released to third parties

or published.

4. I agree not to restrict the use of any data or results that arise from this study

provided such a use is only for scientific purposes.

5. I agree to take part in the above study.

Signature of the subject:

Signatory’s name:

Signature of the investigator:

Study investigator’s name:

Signature of impartial witness:

Name of impartial witness:

Date:

89

90

CERTIFICATE

This is to certify that this dissertation titled “ANALGESIA FOR

THE PERFORMANCE OF SPINAL ANAESTHESIA IN SITTING




BLOCK” of the candidate DR.M.NISHANTHI with registration number

201720106 for the award of M.D degree in the branch of MD in

Anaesthesiology and Critical care. I personally verified the urkund.com

website for the purpose of plagiarism check. I found that the uploaded

thesis file containing from introduction to conclusion pages and result

shows 24 percentage of plagiarism in the dissertation.

DR.M.KALYANASUNDARAM M.D.,

Professor



Madurai-20

91

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ANALGESIA FOR THE PERFORMANCE OF SPINAL ANAESTHESIA …