Fascia Iliaca and Biers blocks in Emergency room

Extremity blocks

Bier’s Block &Facia Iliaca block -FICB in ER

Dr.Venugopalan .P.PDA,DNB,MNAMS,MEM[GWU]Director ,Emergency Medicine Aster DM Healthcare India

Disclaimer

Every effort was made to ensure that material and information contained in this presentation are correct and up-to-date. The author can not accept liability/responsibility from errors that may occur from the use of this information. It is up to each clinician to ensure that they provide safe anesthetic care to their patients.

Anaesthesia /EM

Intravenous Regional Anaesthesia(Bier’s Block)

Introduced by August Bier in 1908Bier block is a technique for

intravenous regional anesthesia Produce total analgesia of either

the upper or lower extremity. Best reserved for short procedures

(less than 60 minutes) of the distal extremities.

Bier block

How does it work?❖ The technique is based on the premise that if

circulation to the limb is blocked and local anesthetic is injected into venous vessels distal to the occlusion,

❖ The nerves that typically travel with blood vessels will be anesthetized as the drug diffuses into the ex- travascular space via retrograde flow.

❖ The duration of the block depends on the length of occlusion of the vessels.

Hypothesis on mechanism of action

Adapted from Rosenberg and Heavner, 1985

Why Bier block

Easy to administerRapid recoveryRapid onsetMuscle relaxation

What procedures ?

Open procedures of the hand or lower arm Closed reductions of the hand or lower arm

What limits you ?

Time! Ideal for procedures lasting 40-60 minutes Maximum time limit is 90 minutes Tourniquet pain generally starts after 20-30 minutes

IVRA

What are the contraindications?

Reynaud’s disease Homozygous sickle cell disease Crush injuries Young Children Must have a reliable/operative tourniquet! If this can not be guaranteed then this technique should not be used due to risk of toxicity!

What are the equipment?

Operative and reliable double tourniquet Running IV in non-operative arm Resuscitation equipment Eschmark bandage

What agents?

0.5% lidocaine or 0.5% prilocaine Dose is 3 mg/kg for either NEVER USE EPI CONTAINING SOLUTIONS Complication of prilocaine is methemoglobinemia in doses of > 10 mg/kg

Caution !

Intravenous Regional Anaesthesia

How do you perform?

Bier’s Block

IVRA - Bier’s Block

How do you do ?

IV catheter in operative arm as distally as possible

IVRA / Bier’s block

How do you do it?

Double tourniquet on the operative arm

IVRA /Bier’s Block

How do you do it?

Have patient hold arm up. Use Eschmark to exsanguinate the arm Exsanguinate the arm from distal to proximal.

IVRA /Biers block

How do you do ?

Inflate the proximal tourniquet to 150 mmHg over the patients systolic pressure

Proximal Cuff

Distal Cuff

Procedure

IVRA

Confirm the absence of a radial pulse

Procedure

IVRA

Inject your local (0.5% Lidocaine or Prilocaine in a dose of 3 mg/kg)

Procedure

IVRA

• Remove IV catheter • Hold pressure and have

OR staff prep arm. • Onset of anesthesia

should occur in 5 minutes

Procedure

IVRA

When the patient complains of pain you can inflate the distal tourniquet and then deflate the proximal tourniquet

Proximal Cuff

2nd

Distal Cuff

1st

When & How to release tourniquet?

The tourniquet should be up for at least 25 minutes… Early release may result in toxicity Releasing the tourniquet in cyclic deflations (10 second intervals) will decrease peak levels of local anesthetic

What are the complications ?

Tourniquet discomfort Rapid return of sensation after tourniquet release and subsequent surgical pain Toxic reactions from malfunctioning tourniquets or deflating the tourniquet prior to the 25 minute limit

How do you identify LA toxicity

Circum-oral parasthesia Facial twitching Tinnitus Focal convulsions Generalised convulsions Respiratory arrest Cardiac arrest

How do you manage it

A= airway. Maintain a patent airway, administer 100% oxygen.

B= breathing. May need to assist the patient with positive pressure ventilation or intubation.

C= circulation. Check for a pulse. If no pulse, initiate CPR.

How do you manage it?

Seizures. Diazepam in doses of 5 mg, or alternatively sodium pentothal in doses of 50-200 mg will decrease or terminate seizures. Hypotension. Treat with ephedrine (typically 5 mg) IV, open up intravenous fluids, place the patient in a head down position (Trendelenburg). If hypotension is refractory to ephedrine, treat the patient with epinephrine (5-10 mcg). Repeat and escalate the dose as necessary.

The use of lipids in the treatment of local anesthetic toxicity has shown promise.

Prilocaine Treat with 1-2 mg/kg of 1% methylene blue given over 5 minutes

Bier Block Study

10 patients were enrolled in this prospective study.

The aim was to study the onset, the order of sensory anesthesia, and plasma serum levels of lidocaine were measured at 1,5,10,15,20,25,30,45,60, and 90 minutes after the tourniquet was released.

The tourniquet was elevated for a minimum of 30 minutes prior to release.

Simon, Gielen, Vree, Booij. Disposition of lignocaine for intravenous regional anaesthesia during day-case surgery. European Journal of Anaesthesiology. Pp 32-37. 15(1), 2006.

Bier Block Study Results

Mean onset of action for lidocaine was 11.2 minutes (+/- 5.1 minutes).

No fixed sequence of anesthesia (radial, median, and ulnar distributions).

No patient exhibited toxicity.

Simon, Gielen, Vree, Booij. Disposition of lignocaine for intravenous regional anaesthesia during day-case surgery. European Journal of Anaesthesiology. Pp 32-37. 15(1), 2006.

Bier Block Study Results

8 of the 10 patients reached the maximum plasma concentrations of lidocaine 1 minute after tourniquet release.

2 of the 10 patients had a slow release and peak in concentration of lidocaine.

Delayed release of lidocaine may be explained by a greater degree of absorption into tissue of the arm.

Simon, Gielen, Vree, Booij. Disposition of lignocaine for intravenous regional anaesthesia during day-case surgery. European Journal of Anaesthesiology. Pp 32-37. 15(1), 2006.

J Pediatr Orthop. 1991 Nov-Dec;11(6):717-20.

❖ J Pediatr Orthop. 1991 Nov-Dec;11(6):717-20.

❖ Intravenous regional anesthesia: a safe and cost-effective outpatient anesthetic for upper extremity fracture treatment in children.

❖ Barnes CL1, Blasier RD, Dodge BM.

❖ Author information

❖ 1Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock 72205.

❖ Abstract

❖ We reviewed our most recent 100 consecutive cases with respect to efficacy and safety of anesthesia in which Bier block anesthesia was used to reduce upper extremity fractures. Records were reviewed to document diagnosis, number of reduction attempts, efficacy of anesthesia, and

incidence of complications and untoward effects. No adverse effects were noted from lidocaine injection or tourniquet release. The cost of Bier block anesthesia administered in the emergency room (ER) was significantly less than that of a general anesthetic in the operating room. We have found the Bier block to be a safe, reliable, and cost-effective anesthetic in treatment of children's upper extremity fractures in the ER.

❖ Intravenous regional anesthesia: a safe and cost-effective outpatient anesthetic for upper extremity fracture treatment in children. [J Pediatr Orthop. 1992]

Teaching points ❖ Never deflate the tourniquet sooner than 20 minutes after injection,

even if the surgery is shorter than that time period

❖ The lidocaine has been injected intravenously and toxicity can occur with early cuff deflation.

❖ Because of the possibility of intravenous injection, epinephrine is not used in the local anesthetic solution

❖ Short-acting, less toxic local anesthetics are employed (lidocaine or prilocaine).

❖ Do not use ropivacaine or bupivacaine

Lorem Ipsum Dolor

Fascia Iliaca Block FICB

Fascia Iliaca Compartment Block -FICB

★Described by Dalens et al ★ It is a low-skill ★ Inexpensive ★ Provide peri-operative analgesia in

patients with painful conditions ★Thigh, the hip joint and/or the femur ★Use of ultrasound to aid

identification of the fascial planes may lead to faster onset, denser nerve blockade and an increased rate of successful blocks

Fascia Iliaca Compartment Block❖ Compartment block

❖ Volume is the key.

❖ Goal is not to place the local solution next to nerve

❖ Local anesthetic into an anatomical compartment containing nerves

❖ Let the distribution of the local solution within the compartment take the local to the nerves.

❖ Adequate volume for the block.

Anatomy Key points:

• Innervation of medial, anterior and lateral aspects of thigh comes from L2 to 4 • Fascia iliaca compartment contains three of four major nerves to the leg • Local anaesthetic injected here reliably reaches the femoral and LFCN only

Lumbar Plexus

❖ Nerve roots from the T12 through L5 vertebrae.

❖ The largest branch of the lumbar plexus is the Femoral nerve is, arising from the L2, L3, & L4 roots.

Femoral Nerve -FN

❖ Descends through the fibers of the psoas major

❖ Exits at the lower portion of the psoas' lateral border,

❖ Passing downward between the psoas and iliacus muscle, deep to the iliacus fascia.

❖ Exits the pelvis into the upper thigh, lateral to the common femoral artery and vein

Lateral Femoral Cutaneous Nerve-LFCN

❖ Purely sensory nerve arising from the L2 & L3 nerve roots

❖ Provides sensation from the iliac crest down the lateral portion of the thigh to the area of the lateral femoral condyle.

❖ Emerges from the lumbar plexus and travels downward lateral to the psoas muscle

❖ Crosses the iliacus muscle deep to the iliacus fascia.

Obturator Nerves -A &P❖ Innervate a portion of the

distal, medial thigh. ❖ L2, L3, & L4 nerve roots ❖ Cross the iliacus muscle, deep

to the fascia, to the medial thigh.

❖ Involved in the FICB❖ Probably plays little role in

post-operative pain relief of hip and proximal femur.

Fascia Iliaca Compartment Block

Approach

How do you do it ? Videos

Approach

Fascia Iliaca Compartment Block

Ultrasound Guided approach

Equipment needed

• Ultrasound machine with linear transducer (6-14 MHz)

• Sterile sleeve • Gel • Standard nerve block tray • Two 20-mL syringes containing

local anesthetic • 80- to 100-mm, 22-gauge

needle (short bevel aids in feeling the fascial ‘pops')

• Tuohy needle is better • Sterile gloves

Facia Iliaca Compartment Block - USG guided

✤The transducer should be placed at the level of the femoral crease and oriented parallel to the crease.

Make sure you are looking at iliacus fascia.

FICB❖ The sartorius muscle crosses the iliopsoas just after it passes

over the edge of the ilium .It passes under the inguinal ligament.

❖ The simplest way to find the correct fascial layer is to clearly identify the ilium (bone) on ultrasound.

USG -Guided

FICB

❖ The muscle lying in contact with the bone and directly overlying it, is the iliacus muscle

❖ The fascial layer covering it is the iliacus fascia.

USG Guided

Ultra sound anatomy

A panoramic view of ultrasound anatomy of the femoral (inguinal) crease area. From lateral to medial shown are tensor fascia lata muscle (TFLM), sartorius muscle (SaM), Iliac muscle, fascia iliaca, femoral nerve (FN), and femoral artery (FA). The lateral, middle and medial 1/3s are derived by dividing the line between the FA and anterior-superior iliac spine in three equal 1/3 sections.

Sartorius Muscle Tensor Fascia Lata Muscle

Approach

FICB

Sonological Anatomy

FICB-USG Guided

FICB-UGG Guided❖ Advance the needle In-Plane so

that you can see its passage in the subcutaneous tissue moving superiorly.

❖ Angle the needle to try to cross the iliacus fascia about midway across the bony edge of the ilium.

❖ You should feel a pop and see the needle tip puncture the iliacus fascia.

FICB -USG Guided

❖ Introduce the needle at the rim of the ilium

❖ Nerves arise from the lumbar plexus

❖ They are coming from the superomedial edge of the ilium.

FICB-USG Guided

❖ Watch for the local solution to move superiorly as you inject.

❖ Local solution needs to travel superiorly to encounter them at the earliest opportunity

FICB-USG guided❖ Ensure that the solution travels

superiorly, after inserting the needle through the iliacus fascia

❖ Injecting a small amount of solution, advance the needle tip superiorly, under ultrasound, into the space created by the injected local solution

❖ Needle tip must remain beneath the fascia and above most of the iliacus muscle as it is advanced.

FICB -USG Guided

❖ Observe injected local solution expanding or “running off” towards the superior edge of the iliacus muscle on the ultrasound image.

❖ It is alright if your local solution is injected within the body of the iliacus muscle

❖ Try to keep it in the superficial (anterior) portion if possible.

How much local Anaesthetics ?

❖ Total of 50 ml of local anesthetic mixture injected incrementally, 10 – 15 ml after needle placement

❖ Advance the needle into the space created by the volume, then inject the remainder of the local anesthetic mix.

What drug?

❖ Bupivacaine❖ Ropivacaine ❖ Lignocaine with Epinephrine

Video

FICB-EBM

Bier’s Block FICB

Site Upper and Lower Limbs Lower Limb

Type Vascular route Compartment Route

Basis Volume Based Volume Based

USG No need of GSG USG Guided is the best option

Drugs Can’t Use EPI,BUPI &ROPI Can Use it safely

Duration Duration 30mts Upto 2 hours

Tripple Nerves Radial,Ulnar,Median FN,LCNT,Obturator

Tourniquet Need tourniquet No role for tourniquet

Comparative Summary

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