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Suprainguinal Fascia Iliaca Block as a Novel Approach to Hip Fracture Surgical Pain: A Case Report
Brooke Calabrese, MD and Jillian Vitter, MD
The incidence of hip fractures is projected to increase as our population continues to age. This poses large utilization and cost burdens on the medical system (4). Despite the frequency of hip fracture surgeries and orthopedic society recommendations for regional analgesia, there is no agreed upon optimal peripheral nerve block to aid in patients’ recovery. The fascia iliaca nerve block has been previously studied, but there is variable coverage of the lateral femoral cutaneous nerve (LFCN) often needed to cover incisional pain. Recent reports of a suprainguinal approach to the fascia iliaca block for total hip arthroplasty (THA) have demonstrated coverage of both the femoral nerve and LFCN (1, 2). A randomized trial of patients undergoing THA receiving either suprainguinal or conventional infrainguinal fascia iliaca block showed a statistically significant reduction in opioid consumption with the suprainguinal fascia iliaca (SIFI) block (3). To date, the SIFI block has not been studied in hip fracture patients. This case report describes the use of a SIFI continuous catheter as rescue analgesia for a patient with exquisite opioid sensitivity and multiple opioid-related hypercapnic respiratory failure and cardiac arrests.
Verbal informed consent was obtained from the patient for this case report.
DB is a 67 year old male with pulmonary hypertension, dialysis-dependent renal failure, congestive heart failure, and history of multiple prior PEA arrests who presented with left displaced femoral neck fracture after a fall at home. DB underwent a left-sided hemiarthroplasty, along with chest tube placement for a right-sided pleural effusion found on admission. DB could not be extubated in the OR due to apnea and was transferred intubated to the ICU. The patient was extubated on post-operative day #2 but required emergent reintubation after hypercarbic respiratory failure following 5mg PO oxycodone. On post-operative day #3 the acute pain service was consulted for non-opioid analgesia. A SIFI continuous catheter was placed for pain control. Under ultrasound guidance, the suprainguinal approach was used and an initial bolus of 40ml bupivacaine 0.25% was given with visualized spread above the iliacus muscle. A 20G epidural catheter was left in place. The catheter was infused with ropivacaine 0.2% at 10ml/h and the patient received a 20-30ml bolus of bupivacaine 0.25% daily. The patient was successfully extubated the morning following catheter placement. The catheter remained in place for a total of 4 days and the patient did not require any opioids for comfort.
While the SIFI block has been described in the use of THA, it has yet to be described for patients with hip fracture. DB was a medically complex patient who had severe pain from a femoral neck fracture, but was unable to be extubated due to opioid-induced hypoventilation. After placement of SIFI catheter he was taken off all opioids and extubated. SIFI block is being explored at our institution for hip fracture patients, especially in patients at high risk for adverse effects of opioids, including hypoventilation and delirium. There is a need for prospective studies on the use of SIFI in hip fractures.
1. Bullock WM et al. "Ultrasound-Guided Suprainguinal Fascia Iliaca Technique Provides Benefit as an Analgesic Adjunct for Patients Undergoing Total Hip Arthroplasty." Journal of Ultrasound in Medicine. 2016;36(2):433-438.
2. Hebbard P et al. "Ultrasound-guided supra-inguinal fascia iliaca block: a cadaveric evaluation of a novel approach." Anaesthesia. 2011;66(4):300-305.
3. Kumar et al. "Comparison of conventional versus modified proximal suprainguinal approach of Fascia Iliaca Compartment Block for postoperative analgesia in Total Hip Arthroplasty. A prospective randomized study." Acta Anaesthesiologica Belgica. 2015; 66(3): 95-100.
4. Opperer M et al. “Perioperative outcomes and type of anesthesia in hip surgical patients: an evidence based review.” World Journal of Orthopedics. 2014; 5(3): 336-343.