Clinical Practice Manual - SVH Fascia Iliaca Block For Preoperative .
St Vincent’s Health Network Sydney- Policies and ProtocolsMonday, 15 August 201612:39Policies & ProtocolsClinical Practice Manual- SVH Fascia Iliaca Block for PreoperativePain Managment in Adults with a FracturedNeck of Femur ProtocolProtocol:ObjectiveTo ensure patients with suspected or confirmed Fractured Neck of Femur (NOF)are provided with safe and effective best practice pre-operative pain relief throughadministration of Fascia Iliaca Block (FIB).This procedure outlines the following:1. Roles and Responsibilities2. SVH Training Framework for Clinicians New to Inserting Fascia Iliaca Blocks3. Process1. Determining appropriateness2. Equipment3. Preparation4. Procedure4. Troubleshooting and Complications5. Post procedure patient management6. Disposal of waste and equipment7. Documentation8. CompliancePrinciples of ActionThe principles of action to minimise pain and associated risks for patients withsuspected or confirmed fractured neck of femur includes the following: Conducting regular pain assessment and documentation Initiating Fascia Iliaca Block (ultrasound guided) for consented patients withsuspected or confirmed fractured neck of femur as soon as possible Ensuring patients / carers are provided patient education on Fascia Iliaca Block Ensuring patients are continually assessed for ongoing pain and pain managementstrategies are implemented.DefinitionsTraumaticTraumatic injury is an injury to the body that occurs when aInjuryphysical force contacts the body.Fascia IliacaBlock (FIB)A technique used to block the sensation in the femoral nerveas a means of controlling pain prior to surgerySuspectedOn examination, the affected extremity is often shortened andFractured Neck unnaturally, externally rotated compared to the unaffected leg.of FemurThe patient is experiencing pain and is unable to weight bearConfirmedOn examination, the affected extremity is often shortened andFractured Neck unnaturally, externally rotated compared to the unaffected leg.of FemurPlus medical confirmation by either x-Ray, MagneticResonance Imaging (MRI) or Computed Tomography (CT)In PlaneThe needle enters the skin at the side of the probeGeneral Page 1
In PlaneApproach (IP)The needle enters the skin at the side of the probeOut of Plane(OOP)The needle enters the skin away from the probe, and is aimedat the plane of soundClinicianMedical or nursing clinician who is authorised to insert FIB andis new to this procedure at SVHSupervisorStaff Specialist / Registrar with experience inserting FasciaIliaca BlocksFailed BlockVisual Numerical Pain Score (VNPS) not decreased by 30%within 40 minutes of FIB insertionRoles and ResponsibilitiesScopeThis procedure applies primarily to patients with suspected orconfirmed Fractured NOF. Consider FIB in proximal to mid shaftfractured femurs.FIBs are excluded for those patients with any of the following: Known sensitivity to local anaesthetics Previous vascular surgery of the effected limb Unable to identify femoral artery Patients on anticoagulant agents such as Warfarin (withINR 1.4), Clopidogrel, Low Molecular Weight Heparin (withinprevious 12 hours), Heparin (within previous 6 hours),Dabigatran, Rivaroxaban and other medications within theThienopyridine class Meet any of the Ropivacaine contraindications.ResponsibilitiesAnaesthetists are responsible for: Maintaining their knowledge and skills of Fascia Iliaca Block in line withthe SVH Training Framework for Clinicians New to Inserting Fascia IliacaBlocks. Anaesthetists may initiate Fascia Iliaca Block after: Reviewing the patient’s full medical history and principal diagnosis Comparing the patient’s medical history and principal diagnosis with thepatient criteria outlined in Scope which are excluded from FIB.Supervised Anaesthetic and Supervised Pain Fellows are responsiblefor: Maintaining their knowledge and skills of Fascia Iliaca Block in line withthe SVH Training Framework for Clinicians New to Inserting Fascia IliacaBlocks. Safely completing at least 2 observed FIB with an ED Staff Specialist,accredited Registrar or Anaesthetist prior to being assessed ascompetent with FIBs Demonstrating competency in insertion of FIB prior to performing FIBindependently. Supervised Anaesthetic and Supervised Pain Fellows who havedemonstrated competency ARE permitted to initiate Fascia IliacaBlock after: Reviewing the patient’s full medical history and principal diagnosis Comparing the patient’s medical history and principal diagnosis with thepatient criteria outlined in Scope which are excluded from FIB. Supervised Anaesthetic and Supervised Pain Fellows who fail to insertFIB after one attempt, should make no further attempts at FIB and seekassistance from an Anaesthetist before attempting another FIB.Emergency Department Staff Specialist and Supervised EDRegistrars are responsible for:General Page 2
Registrars are responsible for: Maintaining their knowledge and skills of Fascia Iliaca Block inline with the SVH Training Framework for Clinicians New toInserting Fascia Iliaca Blocks. Safely completing at least 2 observed FIB with an ED StaffSpecialist, accredited Registrar or Anaesthetist prior to beingassessed as competent with FIBs Demonstrating competency in insertion of FIB prior toperforming FIB independently. ED Staff Specialists, Supervised ED Registrars who havedemonstrated competency ARE permitted to initiateFascia Iliaca Block after: Reviewing the patient’s full medical history and principaldiagnosis Comparing the patient’s medical history and principal diagnosiswith the patient criteria outlined in Scope which are excludedfrom FIB. ED Staff Specialists and Supervised ED Registrars who fail toinsert FIB after one attempt, should make no further attemptsat FIB and seek assistance from an Anaesthetist beforeattempting another FIB.Emergency Department Clinical Nurse Specialists 2 (CNS2),Clinical Initiatives Nurses (CINs) and Clinical NurseConsultant (CNC) Acute Pain Competent in FIBs areresponsible for: Maintaining their knowledge and skills of Fascia Iliaca Block inline with the SVH Training Framework for Clinicians New toInserting Fascia Iliaca Blocks. Safely completing at least 2 observed FIB with an ED StaffSpecialist, accredited Registrar or Anaesthetist prior to beingassessed as competent with FIBs. Demonstrating competency in insertion of FIB prior toperforming FIBs independently. ED CNS2, CIN’s and CNC Acute Pain who havedemonstrated competency ARE permitted to nurseinitiate Fascia Iliaca Block without a MO’s order after: Reviewing the MO’s documentation of the patient’s full medicalhistory and principal diagnosis Comparing the patient’s medical history and principal diagnosiswith the patient criteria outlined in Scope which are excludedfrom FIB. ED CNS2, CIN’s and CNC Acute Pain who fail to insert FIB afterone attempt, should make no further attempts at FIB and seekassistance from a medical officer before attempting anotherFIB.Director Emergency Department is responsible for: Ensuring ED Staff Specialists are competent in the insertionand management of FIBs in line with the SVH TrainingFramework for Clinicians New to Inserting Fascia Iliaca Blocks. Monitoring and managing ED Staff Specialist clinical practice inrelation to FIBs outside of the scope of this clinical procedure.Emergency Department Nurse Manager and Nursing UnitManagers are responsible for:General Page 3
Managers are responsible for: Ensuring nursing staff are competent in the insertion andmanagement of FIBs in line with the SVH Training Frameworkfor Clinicians New to Inserting Fascia Iliaca Blocks. Essential equipment is available on the clinical unit for nursingstaff and ED Staff Specialists to perform FIBs. Monitoring and managing nursing clinical practice in relation toFIBs outside of the scope of this clinical procedure.ProcessDetermine Appropriateness of Fascia Iliaca BlockBefore placing FIBs:1. Complete and/or review the patient medical assessment anddocumentations, including ECG.2. Confirm and document the need for FIB.3. Consider the indications for FIBs - preoperative painmanagement for patients with confirmed or suspectedfractured neck of femur.4. Consider the contraindications for FIBs - FIBs are excluded forthose patients with any of the following: Known sensitivity to local anaesthetics Previous bypass vascular surgery of the effected limbinvolving the iliac or femoral vessels Unable to identify femoral artery Known anticoagulant problems including clotting disorders Patients on anticoagulant agents such as Warfarin (withINR 1.4), Clopidogrel, Low Molecular Weight Heparin(within previous 12 hours), Heparin (within previous 6hours), Dabigatran, Rivaroxaban and other medicationswithin the Thienopyridine class Meet any of the Ropivacaine contraindications including: Allergy to Ropivacaine, Paracetamol or Morphine Anticoagulated patients or those with significantcoagulation abnormalities that increase risk of bleeding Localised injection site infections Women lactating or pregnant Documented severe hepatic disease Documented evidence of second of third degree heartblock on ECG (unless patient has a personal pacemaker) Amiodarone therapy.NB: Aspirin alone and / or Non SteroidalAntiinflammatory Drugs (NSAIDs) alone are notcontraindicated.Equipment: Plain Lignocaine 1% (5mL) for local anaesthetic to skin Plain Ropivacaine 0.75% Normal Saline 0.9% for injection Dressing Pack Sterile Gloves Chlorhexidine Gluconate Swabs 2% w/v in 70% v/v/ IPA (Hydrex 2%Alcohol) Sterile Gel Intravenous cannulas as appropriate for patient1 litre Hartmann’s SolutionGeneral Page 4
1 litre Hartmann’s Solution Luer Lock Syringes (20mls x 2) 22 G x 50mm Sono Tap Cannula Small dressing Ultrasound machine with linear array ultrasound probe usually in the midto high frequency range (e.g.-8-10 MHz Marking Pen. Monitoring Equipment Electrocardiography (ECG) Blood Pressure Monitor / Sphygmometer Pulse Oximeter. Assistant. Ideally this is a 2 operator procedure. If availableenlist assistance for the procedure to ensure safe patientcare.Preparation1. Confirm the patient’s identification2. Introduces themselves to the patient3. Offers the patient opportunity for a member of staff or relative orfriend to present with them during the procedure4. Educates the patient (and relative / friend, if present) about theprocedure and explains the reason for the FIB)5. Obtain and documents patient verbal consent which aligns with theprinciples of the SVH Informed Consent Policy6. Assesses and documents pain7. Performs hand hygiene and prepares equipment8. Set up the sterile dressing pack on a dressing trolley, IVequipment , local anaesthetic (Table 1)9. Set up monitoring equipment (ECG, pulse oximetry, blood pressuremeasurement, and respiratory rate)10. Positions the patient in a supine position with the relevant lowerlimbs slightly abducted and externally rotated if possible.Procedure1. Gain venous access preferably using a 18G or 19G cannula2. Start Hartmann’s solution (1lite over 8 – 12 hours), unlessotherwise indicated3. Draw up 5mL of 1% Lignocaine4. Make up 0.375% Ropivacaine by diluting Ropivacaine 0.75% withan equal volume of 0.9% Sodium ChlorideTo achieve this: in TWO separate 20mL syringes draw up 10mLof 0.75% Ropivacaine into each syringe. Dilute each 20mLsyringe with 10 mLs of 0.9% Sodium Chloride to a total of20mL in each syringsDetermine volume required according to patient weight andusing Table 1. Discard excess and administer required volume.Table 1. Local Anaesthetic to Weight Ratio TableEstimate Weight of Volume of Ropivacaine 0.375% (inPatient / kgmL)(1:1 of 0.75% Ropivacaine andwith 0.9% Sodium Chloride) 602561-7030General Page 5
61-7030 71355. Monitor the patient throughout the procedure including ECG, pulseoximetry, frequent blood pressure measurement, respiratory rate,and level of consciousness6. Stand on the injured side of the patient within comfortable reach ofthe area to be surveyed (between the femoral artery and anteriorsuperior iliac spine)7. Palpate the anterior superior iliac spine (ASIS) and mark the medialborder. Palpate the femoral artery and mark it’s position (Figure 1)8. Ensure the ultrasound video screen is opposite for easy viewing andto enable the clinician to hold the ultrasound probe in their nondominant hand and the needle in the dominant hand9. Identify the orientation of the ultrasound probe for which is medialand which is lateral (Figure 1)10. Anaesthetise with 1% lignocaine the insertion point approximately 2cm lateral to the femoral artery and 1 cm inferior to the inguinalligament11. Maintain strict asepsis throughout procedure12. Clean the skin with Chlorhexidine Gluconate swabs 2% w/v in 70%v/v IPA (Hydrex 2% Alcohol)13. Apply gel and place the ultrasound probe parallel to the inguinalligament, between the ASIS, and the femoral artery14. Palpate and place the probe over the ASIS first then move theprobe medially along the line of the inguinal ligament (Figure 1)15. Move the probe medially and identify the relative location of thecommon femoral arteryFigure 1. Right sided Fascia iliaca infrainguinal approachFigure 2. Insert the needle using an OOP approach for theinfrainguinal fascia iliaca blockGeneral Page 6
infrainguinal fascia iliaca block16. Palpate for the ASIS and then move the probe over it and visualizeit on ultrasound Move the probe medial 2 – 3 cms and inferior andidentify the edge of the ilium17. Identify the muscle covering the ilium and descending into thepelvis (the iliacus muscle.18. The bright band covering the iliacus is the fascia iliacus19. Move the probe superiorly over the edge of the ilium so that theecho-reflective curve of the ilium is on the inferior side of theultrasound survey picture and you can clearly see the fascia andiliacus muscle20. Stabilize the hand holding the ultrasound probe to minimizemovement21. Use an Out-of-Plane (Figure 2) needle approach for this block byangling the needle so that you can track its progress to the targetarea22. Angle the needle to try to cross the iliacus fascia about midwayacross the bony edge of the ilium. You should feel a release and seethe needle tip puncture the iliacus fascia23. Keep the needle tip in the superficial layers of the iliacus muscle toallow the injected solution to spread cephalad and the block will stillwork. Once the needle tip is sub-fascial, aspirate and inject a 2 – 5mLs of the local solution to see how it spreads.24. Ideally the solution will lift the fascia off of the superficial layer ofthe iliacus muscle and spread in a superior direction25. If the needle tip is within the iliacus muscle, you will note themuscle fibres spreading apart and solution moving in the superiordirection26. After injecting 5 – 10 mLs, advance the needle another centimetreor 2 while watching on ultrasound. Advancing the needle will helpthe solution to move superiorly during subsequent injection.27. After the needle is advanced into the space made by the initialinjection, inject the remainder of the local solution slowly over 1½ 2 mins, aspirating every 5mL of administration to optimise theGeneral Page 7
2 mins, aspirating every 5mL of administration to optimise thespread of anaestheticNB: DO NOT ADVANCE THE NEEDLE BLINDLY INTO THE SPACECREATED BY THE INJECTED VOLUME.ALWAYS USE THE ULTRASOUND TO MONITOR THE NEEDLE'SADVANCE.THE NEEDLE POSITION WILL BE PHYSICALLY CLOSE TO THEPELVIC CAVITY AND ADVANCING BLINDLY COULD CAUSEINADVERTENT PUNCTURE OF THE PELVIC CAVITY.After initiating the FIB it is the responsibility of the proceduralist toremain immediately available until satisfactory block has beenachieved, the patient is stable, and the potential for immediatecomplications has passed28. Watch carefully during injection to make sure that the solution ismoving in the superior or cephalad direction. Adjust the needleposition, if necessary, to correct placement of the solutionTroubleshooting & ComplicationsInadvertent Intravascular InjectionObserve the patient for any signs of inadvertent intravascularinjection such as: Circumoral tingling Light Headedness Visual Disturbances Seizures Arrhythmias. Stop injecting the local anaesthetic Call for Rapid Response and follow basic life support guidelines Administer 100% oxygen.If any of the above occur: Stop injecting the local anaesthetic Call for Rapid Response and follow basic life support guidelines Administer 100% oxygen.ToxicityReaction to local anaesthetic signs Early signs: circumoral numbness (earliest), tongue paresthesiaparesthesia, dizziness. Excitatory signs such as restlessness and agitation often precede CNSdepression (slurred speech, drowsiness, unconsciousness) Muscle twitching heralds the onset of tonic, tonic- clonic seizures Respiratory arrest often follows.Treatment for the above is: Stop injecting the local anaesthetic Administer 100% oxygen Call ED Staff Specialist or Registrar and follow basic life supportguidelines If patient is unresponsive to standard therapy, in addition to standardcardio-pulmonary resuscitation, commence lipid rescue includingadministering Intralipid 20% intravenously (IV) in the following doseregime: Intralipid 20% 1.5 mL/kg over 1 minute Follow immediately with an infusion at a rate of 0.25 mL/kg/min, Continue chest compressions (lipid must circulate)Repeat bolus every 3-5 minutes up to 3 mL/kg total dose untilGeneral Page 8
Repeat bolus every 3-5 minutes up to 3 mL/kg total dose untilcirculation is restored Continue infusion until hemodynamic stability is restored. Increase therate to 0.5 mL/kg/min if BP declines A maximum total dose of 8 mL/kg is recommended. In practice, in resuscitating an adult weighing 70kg: Take a 500ml bag of Intralipid 20% and a 50ml syringe Draw up 50ml and give stat IV, x 2 Then attach the Intralipid bag to an IV administration set(macrodrip) and run the IV at 0.25 mL/kg/min rate 1050mL/hour(Total vol to be infused 400mL) Repeat the initial bolus up to twice more – if spontaneouscirculation has not returned.Excessive Resistance to InjectionIf you feel excessive resistance to injection, either withdraw the needle slightly oradvance it, depending on what you are seeing in the survey window.Excessive Inferior Runoff of Local SolutionIf there excessive inferior runoff of the local solution (some or too much of the localspreading out in the direction opposite the lumbar plexus).Use one your hands or the hand of an assistant to place manual pressure inferiorto the injection site to encourage antegrade flow towards the lumbar plexus .Failed BlockFailed block is rare and usually due to wrong location orabnormal anatomy. Failed block is recognised when VNPS hasnot decreased by 30% within 40 minutes of FIB insertion.When FIB fails administer regular analgesia as charted and / ornotify ED Staff Specialist or Anaesthetic Consultant.HaematomaUsually a minor complication. Do not perform block whenpatient is anticoagulated (INR 1.4).Nerve DamageVery rare since needle and injection are not near nerve. Likelydue to wrong location or abnormal anatomy. Don’t do insertFIB while patient asleep or heavily sedated as post-operativeneuropathy has been observed with the FIB was performed.Signs of post injection neuropathy can only be recognised ifpain and parathesia in the thigh and knee persists for morethan 12 hours. In this situation information the ED StaffSpecialist or Anaesthetic Consultant.Post Procedure Patient Management1. Monitor the patient 15 mins post procedure, then hourly for 2hours, then 4th hourly thereafter including: BP, pulse, oxygen saturation, respiratory rate and level ofconsciousness Pain assessments using appropriate pain assessment tool (VisualAnalogue Scale or Abbey Pain Scale for confused patients) Observe for block failure (pain at same level as prior to FIB onactivity / on rest)2. Prescribe PRN analgesia including: 2.5mg Oxycodone q1hr x 3 doses in 4 hours (then SRMO review)3. Refer patients for follow up: Within business hours to Acute Pain Service (page 6154/6222) Out of hours / holidays / weekend to Anaesthetic Registrar (page 6892).4. Notify Acute Pain Service or Anaesthetic Registrar when nerve blockGeneral Page 9
4. Notify Acute Pain Service or Anaesthetic Registrar when nerve blockno longer effective (approximately 6- 12 hours) to either: Readminister nerve block Chart regular analgesia and aperients including: Oxycodone 2.5 – 5mg QID PLUS Paracetamol 1gm QID PLUS Coloxyl with senna 2 BD5. Maintain pressure injury prevention strategies.Disposal of Waste/Equipment Dispose of waste and equipment from the FIB in standard waste binsand sharps bins as required Sterile gloves should be removed and hand hygiene performed.Documentation Verbal consent from patient if obtained or not obtained Prescription of Ropivacaine and Hartmanns Fluid as per SVH Policy Record of the procedure, using the FIB insertion sticker and includemethod, drugs and dose used, complications or problems encountered Pre and post pain scores Pre and post procedural cardiovascular monitoring of vital signs, urineoutput, sensory and motor function Neurovascular observations Instructions for subsequent management and post procedural care Prescribe PRN analgesia as outlined in Section 5.4.Compliance1. Pain assessment completed in line with SVH Vital Signs Procedure2. Time to initial analgesia within 1 hour3. Paracetamol charted and given every 6 hours4. Additional opioids charted5. Response to analgesics documented6. Evidence that FIB were inserted for Fractured NOFRisk Rating: MediumAppendices: Appendix 1 - SVH Training Framework for Clinicians New to Inserting Fascia IliacaBlocks & Sample Questions Appendix 2 - Sample Questions Appendix 3 - Fascia Iliaca Block Insertion Logbook Appendix 4 - SVH Clinical Compentency Assessment for Clinical Initiatives Nurses(CIN) & Medical Officers - Fascia Iliaca Block (FIB) Appendix 5 - Fascia Iliaca Block (FIB) Insertion StickerStandard:EQuIPNational Standard 4 Medication SafetyReferences: AcknowledgementAdapted from West Herfordshire Hospitals (2011). Guidelines forInsertion of Fascia Iliaca Compartment Block, for preoperativemanagement in adults with confirmed or suspected fractured neck offemur. Retrieved on 23/02/20913 fromhttp://www.westhertshospitals.nhs.uk/foi publication scheme/disclosure 20Attachment%201.pdfAdapted from Neuraxiom. Com – Ultrasound Guided regional NerveBlocks. Fascia Illiaca Compartment Block.Retrieved on 01/03/2013 fromhttp://www.neuraxiom.com/html/ficb.htmlGeneral Page 10
http://www.neuraxiom.com/html/ficb.htmlScott, D.M. & Chuan, A.C. (2010) Regional Anesthesia – InteractiveDesktop Guide. Blocks of the head, upper and lower extremities andpara-axial region. 2nd edition. AstraZeneca Pty Ltd.Lipid Rescue – Treatment for local anaesthetic induced cardiac arrest.Retrieved on 21/11/2013 us.pdfProcedure photos courtesy of AstraZeneca Pty Ltd, reprinted withpermission. Supporting EvidenceAgency for Clinical Innovation (ACI) Orthogeriatric Model of Care, 2010.Retrieved on 23/02/2013 from http://www.aci.health.nsw.gov.au/data/assets/pdf file/0013/153400/aci orthogeriatrics clinical practice guide.pdfAustralian New Zealand College of Anaesthetists. (2005) Guidelines onInfection Control in Anaesthesia. Retrieved on 05/03/2013 ionalstandards-28.htmlNational Health Service Institute for Innovation and Improvementhttp://www.institute.nhs.uk/quality and value/high volume care/fractured neck of femur facts.html National Standards/Aged Care Standards:Standard 4 – Medication Safety Related SVH and SV&MHS Policies:SVH Pain Assessment & Management PolicySVH Informed Consent Policy Related SVH and SV&MHS Procedures:SVH Elderly Pain Management ProcedureSVH ED Elderly PCA GuidelinesFocus Area(s): Acute and High Dependency Patient Care - Assesment/ManagementLinked PP: Informed Consent Protocol Pain Assessment and Management PolicyDepartments: Clinical Organisation WideRevision History:Date Issued:1/6/2013Date of Last Review:2/8/2016Date of Next Review:22/7/2018Committee(s):SVHN Patient Safety & Quality CommitteeApproved By:Chief ExecutiveUnit Manager:Executive OfficeIdentifier:7535Developing Team: Micheal Pierson Sally Francis Annie ZhengHits since last Publication: 269Suggest change (0 changes already suggested)General Page 11
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Essential equipment is available on the clinical unit for nursing staff and ED Staff Specialists to perform FIBs. Monitoring and managing nursing clinical practice in relation to FIBs outside of the scope of this clinical procedure. Managers are responsible for: Determine Appropriateness of Fascia Iliaca Block
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Fascia Research Congress in Boston (2007), fascia has aroused increasing interest from scientists, clinicians and manual body therapists. The number of research papers on fascia appearing in peer-reviewed journals has rapidly increased, particularly since the late 1980s and mid 2000 (see Fig. 1). Since the publication of the proceedings of the
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The number of research papers on fascia in peer-reviewed journals has shown a steady rise particularly since 2005 (see figure 1). The purpose of the program book for the Third International Fascia Research Congress is to provide you background material to understand recent developments in fascia research.
Oct 31, 2009 · THE FASCIA In order to establish groundwork for the proposed theory, it is necessary to review recent research findings regarding the structure and function of the fascia. The fascia is a metasystem conceived as a complex communication network that
Fascia Research Congress: “Fascia is the soft tissue com-ponent of the connective tissue system that permeates the human body. . . . The scope of our definition of and inter - est in fascia extends to all fibrous connective tissues, including aponeuroses, ligaments, tendons, retinaculae, joint capsules, organ and vessel tunics, the epineuria, the
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