A nerve block should be administered before spinal anaesthesia.

 

Rationale

Nerve blocks are an effective way of providing opioid-sparing analgesia in A+E [1] and the early postoperative period [2].

Fascia iliaca block (FIB) may be preferable to femoral nerve block (FNB)

  • unless FNB is administered with a lateral cutaneous nerve of the thigh (LCNT) block to cover the skin incision site [2]
  • ultrasound guidance improves the accuracy of FIB insertion compared to a ‘blind’ double-click technique [3]
  • ultrasound guidance is preferable for FNB insertion as it avoids the need for additional sedation/opioids during painful use of a nerve stimulator

 

Administering nerve blocks before spinal anaesthesia:

  • is not associated with improved 30-day mortality after hip fracture [4]
  • but enables comfortable patient positioning for spinal anaesthesia, without co-administration of sedation or opioids [5, 6]
  • (hypothetically) enables the use of low-dose spinal anaesthesia (see Standard 3), as surgical skin closure remains painless even if the spinal starts to wear off if surgery is prolonged beyond 2-2.5hrs
  • precludes the need to provide local infiltration analgesia at the end of surgery (the effect of which in comparison to nerve block is yet to be determined in hip fracture patients)
  • and precludes the need to administer intrathecal opioids (see Standard 4)

 

The speed of onset of pre-spinal FIB/FNB is increased using lignocaine [7]. Suggested mix:

  • FIB: 20mls 0.375% levobupivacaine + 20mls 0.5% lignocaine
  • FNB: 10mls 0.375% levobupivacaine + 10mls 0.5% lignocaine

 

Evidence

1. Ritcey B, Pageau P, Woo MY, Perry JJ. Regional nerve blocks for hip and femoral neck fractures in the emergency department: a systematic review. Canadian Journal of Emergency Medicine 2015 Sep 2:1-11. [Epub ahead of print]

2. Rashiq S, Vandermeer B, Abou-Setta AM, Beaupre LA, Jones CA, Dryden DM. Efficacy of supplemental peripheral nerve blockade for hip fracture surgery: multiple treatment comparison. Canadian Journal of Anaesthesia 2013; 60: 230-43.

3. Dolan J, Williams A, Murney E, Smith M, Kenny GN. Ultrasound guided fascia iliaca block: a comparison with the loss of resistance technique. Regional Anesthesia and Pain Medicine 2008; 33: 526-31.

4. White SM, Moppett IK, Griffiths R et al. Outcomes after anaesthesia for hip fracture surgery. Secondary analysis of prospective observational data from 11 085 patients included in the UK Anaesthesia Sprint Audit of Practice (ASAP 2). Anaesthesia 2016; 71: 506-14.

5. Diakomi M, Papaioannou M, Mela A, Kouskouni E, Makris A. Preoperative fascia iliaca compartment block for positioning patients with hip fractures for central nervous blockade: a randomized trial. Regional Anesthesia and Pain Medicine 2014; 39: 394-8.

6. Yun MJ, Kim YH, Han MK, Kim JH, Hwang JW, Do SH. Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block. Acta Anaesthesiologica Scandinavica 2009; 53: 1282-7.7.

7. Cuvillon P, Nouvellon E, Ripart J, et al. A comparison of the pharmacodynamics and pharmacokinetics of bupivacaine, ropivacaine (with epinephrine) and their equal volume mixtures with lidocaine used for femoral and sciatic nerve blocks: a double-blind randomized study. Anesthesia and Analgesia 2009; 108: 641-9.