Efficacy of single-shot fascia iliaca compartment blocks. Tom Brink Promotor: Dr. Ph. van Loon
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1 Efficacy of single-shot fascia iliaca compartment blocks Tom Brink Promotor: Dr. Ph. van Loon
2 Index Introduction About the FICB Methods Results o o o o o Search results Study characteristics Techniques and local anesthetics Efficacy (in general and compared to other methods) Block success and adverse effect rates Discussion and limitations Conclusion
3 Introduction Adequate analgesic strategy is important Systemic analgesics have significant side effects Spinal or epidural anesthesia is not always an option Plexus anesthesia may be difficult to administer and / or carry risks (e.g. nerve damage or local toxicity) The FICB might be the solution
4 About the FICB Lumbar plexus anesthesia Goal is to block the femoral nerve, lateral femoral cutaneous nerve and branches of the obturator nerve and genitofemoral nerve Through fascia lata and fascia iliaca Local spread in fascia iliaca compartment Landmark based two pop and ultrasound guided placement Single shot or catheter placement
5 About the FICB Anatomy Image by Hindawi.com
6 About the FICB Anatomy Images by cursoenarm.net and Jack vander Beek
7 Methods Literature search Medline and Cochrane using PubMed Terms: Fascia and iliaca and block or fascia and iliaca and compartment and block Of all results, abstracts were numbered, listed and screened followed by first inclusion-exclusion round RCT s, Case-Control studies, Audits Prospective Outcomes had to concern clinical efficacy Written in English, single shot technique
8 Methods Of included articles full text version obtained Second inclusion-exclusion round Included articles were grouped Articles for background information added later Data extraction with data extraction form Only objectified data with relevance to clinical efficacy No meta-analysis done due to heterogeneity Statistical analyses in original articles assessed
9 Results - Search results
10 Results - Study characteristics Countries on every continent 13 RCT s, 4 case-no-control studies, 2 case controlstudies and 1 continuous audit Setting: 9 ED, 8 OR, 2 pre-hospital and 1 PACU Target groups: Children, adolescents, adults and elderly Indication: 11 for Hip/femoral bone fracture, 6 for elective hip/femoral bone/knee surgery, 2 for patient positioning and 1 for graft harvesting in burn victims Outcomes: Pain, analgesic consumption, sensory/motor block, patient satisfaction, time to first analgesic request and other (not efficacy related) factors
11 Results - Techniques and L.A. 15 studies used the landmark guided two pop technique 4 studies used ultrasound guided placement 1 study used both techniques 7 used 0,25% bupivacaine, 3 used 0,5% ropivacaine, 2 used 0,25% levobupivacaine, 2 used 2,0% lidocaine with 0,5% bupivacaine, 2 used 0,2% ropivacaine, 1 used 1,5% lidocaine, 1 used 2,0% lidocaine, 1 used 1,0% mepivacaine and 1 used 0,375% ropivacaine
12 Results - Efficacy - General (vs. control)
13 Results - Efficacy - General (vs. sham / no control)
14 Results - Efficacy - vs. Intravenous opiates
15 Results - Efficacy - vs. Other systemic meds
16 Results - Efficacy - vs. Others blocks
17 Results - Efficacy - Techniques
18 Results Success and adverse effects Block success rate (full or partial nerve block) Hanna (2014) 67,00% None Kumie (2015) Not specified None Adverse effects (% of patients) Lees (2014) Not specified 0,9% (0,3% block related) McRae (2015) 82,00% None Godoy Monzon (2007) 100,00% None systemic, 3% local Haines (2012) Not specified 15% (not necessarily FICB related) Krych (2013) Not specified None Lopez (2003) 96,00% None Shariat (2013) 94,00% Not specified Capdevila (1998) Complete block: 34%, partial block: up to 90% None Deniz (2014) 87,50% 5% (not necessarily FICB related) Reavley (2014) Not specified Not specified Diakomi (2014) Not specified None Yun (2009) 100,00% None Wathen (2007) Not specified 4% systemic, 15% local Farid (2010) Not specified None Godoy Monzon (2010) Not specified None systemic, 3% local Foss (2007) 67,00% None Cuignet (2005) 100,00% None Dolan (2008) Landmark based "two pop": 47%, ultrasound: 82% Not specified
19 Discussion and limitations - Discussion Relative paucity of data Generally effective and superior to standard care Superior to intravenous and intramuscular opiates Equal / mildly superior to intravenous NSAID; more research needed Equal to other lumbar plexus blocks but safer or easier Ultrasound technique superior but not always necessary or available Single shot technique superior to continuous infusion
20 Discussion and limitations - Limitations We only searched Medline and Cochrane, not Google scholar or CINAHL No meta-analysis possibleµ Some included studies were non-controlled Only single-shot technique evaluated Side-effects and feasibility not a primary outcome Cost-effectiveness not studied
21 Conclusion The FICB is effective, safe and easy to perform The FICB should be considered in all patients with serious hip, thigh or knee injuries or surgery if there are no contraindications for plexus anesthesia If possible, consider ultrasound guided placement Effectivity may be overestimated Apparently no consensus regarding best practice (type and volume of LA, exact placement technique, ) Further research is warranted
22 Any questions?
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