The Royal College of Emergency Medicine has recently published a Best Practice Guideline1 on the use of fascia iliaca blocks (FIB) in the ED.
Whilst national guidance is always welcome in helping to ensure consistent care and change practice for the better, there are a number of parts of this guidance that differ from our normal practice and what we teach. There are also some areas the guideline ignores altogether.
In this post we aim to explain why we disagree with some areas of the guideline and fill in some of the gaps.
Who should get a block?
We are of the opinion that fascia iliaca blocks should form a standard part of the management of pretty much anyone with a fracture of the hip or femur. It may well not totally replace the need for other forms of analgesia but it is a key tool in providing good pain management and in reducing the need for opiates.
What about patients who haven’t got any pain? Fracturing a long bone is not a painless event. The degree of pain will vary due a range of factors but it is unlikely the patient has no pain. Patients who report minimal pain may do so for a number of reasons. It may be because they are lying still or because they have already received analgesia. In either case patients should still receive a block as they need to be able to move in bed and any analgesia they have received so far will wear off.
One contraindication listed in the RCEM guideline concerned us the most:
Patient unable to report possible analgesia complications/side-effects due to e.g. confusion/dementia/learning difficulties.
This group of patients has the most to gain from FIB. They are exactly the patients that will not be able to complain of pain and therefore their pain is likely to be poorly managed, with all of its attendant complications. It might be technically more challenging to perform the block in some cases but it is wrong to exclude such large proportion of patients likely to present with hip fractures.
What about patients on anticoagulation?
This is a common question which we feel has a pretty simple answer- they get a block.
The AAGBI have produced a very useful guideline 2 on this topic. It highlights that blocks in anticoagulated patients range in risk depending on the type and location of the block. Local infiltration is at the lowest end of the range of risk and epidurals with a catheter at the high end. Fascial blocks are listed as being towards to the lower end of the risk spectrum.
If you fracture a long bone bleeding is going to already have occurred from the fracture site. In our view any additional bleeding from a well performed block is likely to be minimal in comparison and the risks are far outweighed by the benefits of providing decent pain relief.
Ultrasound or landmark technique?
This is the wrong question to ask initially. The first question to answer is whether to perform a supra-inguinal or infra-inguinal block? There is some evidence that a supra-inguinal block provides more consists anaesthesia in normal volunteers3 and better analgesia in patients undergoing hip arthroplasty4.
Our practice is to perform a supra-inguinal fascia iliaca blocks wherever possible. There may be occasions where the supra-inguinal approach is difficult due to patient position or body habitus, in which case an infra-inguinal approach is used. In either case we always advocate the use of ultrasound. Ultrasound is required to perform a supra-inguinal block safely and allows the delivery of local anaesthetic to be much more proximal than an infra-inguinal approach. With an infra-inguinal block ultrasound adds no additional time to perform the block and allows accurate delivery of local anaesthetic into the correct plane. Once you have undertaken ultrasound guided infra-inguinal blocks and seen how many ‘pops’ can be felt, it becomes obvious why the landmark technique sometimes fails.
What needle should you use?
For a document so focused on safety the RCEM guidance has a significant omission. The example proforma suggests using a BD IntegraTM – Blunt Fill Needle. It fails to mention the use of NRFitTM connectors.
NRFitTM is an alternative to the standard Luer connector, designed to prevent inadvertent intravenous injection. NHS providers undertaking regional blocks should be using this system to reduce the risk of harm5. This system requires specific syringes and drawing-up needles alongside the block needle. If you are going to be undertaking regional blocks you should be using the appropriate equipment. Currently we use the BBraun Ultraplex® NRFitTM needles. These show up well on ultrasound and have have the NRfit Connector to stop us doing something stupid.
Fascia iliaca blocks area quick and safe to perform. We advocate performing an ultrasound guided supra-inguinal block whenever possible. Not performing a block in a patient with a hip fracture should be an exceptional event.
- Fascia Iliaca Block in the Emergency Department. The Royal College of Emergency Medicine Best Practice Guideline. May 2020.
- Regional Anaesthesia and Patients with Abnormalities of Coagulation. The Association of Anaesthetists of Great Britain & Ireland, The Obstetric Anaesthetists’ Association, Regional Anaesthesia UK. November 2013.
- Supra-inguinal injection for fascia iliaca compartment block results in more consistent spread towards the lumbar plexus than an infra-inguinal injection: a volunteer study. Reg Anesth Pain Med. Feb 2019 doi: 10.1136/rapm-2018-100092. Online ahead of print. PMID: 30798268
- Comparison of Conventional Infrainguinal Versus Modified Proximal Suprainguinal Approach of Fascia Iliaca Compartment Block for Postoperative Analgesia in Total Hip Arthroplasty. A Prospective Randomized Study. Acta Anaesthesiol Belg. 2015;66(3):95-100.
- Patient Safety Alert. Resources to support safe transition from the Luer connector to NRFitTM for intrathecal and epidural procedures, and delivery of regional blocks. NHS/PSA/RE/2017/004. November 2017