Policy
All patients with hip fractures should receive timely, effective, multi-modal analgesia. As part of this the Departments of Anesthesia and Perioperative Care, Emergency Medicine, Orthopedic Surgery recommend all patients receive an ultrasound-guided fascia iliaca block (FIB) as soon as appropriate and possible as this has been shown to decrease pain, need for opioids, and assist in timely transfer to OR.
Note: When possible, it is preferred that these patients receive a FIB catheter placed so that a continuous infusion of anesthetic can be initiated during the hospitalization.
As soon as a patient with acute hip fracture is identified, Orthopedic Surgery consult should be notified by the ED provider.
The ED provider should page the Anesthesia Acute Pain Service 24/7 (at 443-6889) to notify them of the patient.
- If the APS or regional anesthesia team is able to perform the procedure within 2 hours (Mon-Fri, 8am-5pm), then the ED will request placement of a FIB catheter (or one-time FIB, at discretion of APS or Regional Anesthesia team performing the block).
- If a catheter is placed, the APS or Regional Anesthesia team will administer a one-time dose of anesthetic; continuous infusions of anesthetic will only be done once the patient is admitted to an appropriate inpatient unit
- If the APS cannot respond within a reasonable amount of time (outside of Mon-Fri, 8am-5pm; or if APS team is otherwise unavailable), then the ED provider should proceed to performing a one-time FIB (or placement of a catheter, at discretion of ED provider).
- During off hours, the APS may consider requesting assistance from the E1, as appropriate and notifying the ED provider if an Anesthesia provider can respond urgently
- If the APS cannot respond urgently and the ED provider cannot perform the FIB, then the APS will collect the patient’s information and perform a timely consultation at the earliest opportunity to assess ongoing need for FIB. The APS consult will normally not come in from home during weekends or evenings/overnights specifically to perform the procedure.
- If a FIB catheter is placed, then the APS will follow the patient as a consult service.
Note: The FIB should be performed after call to the Orthopedic Surgery consult resident. While it is preferred that the consult resident evaluate the patient prior to or during FIB being performed, the ED or APS teams should proceed to performing the block as quickly as possible in the event of a delay to Orthopedic consultation. Unless there are specific concerns, the FIB should not be delayed until the patient is staffed with or evaluated by the Orthopedic Surgery senior resident or attending physician.
Fascia Iliaca Block Procedure/Protocol and Management of Toxicity
Contraindications to FIB:
- Coagulopathy or anticoagulant use, refer to : https://anesthesia.ucsf.edu/clinical-resources/guidelines-use-antithrombotic-agents-setting-neuraxial-procedures
- Allergy to local anesthetic
- Pre-existing peripheral neuropathy/neuromuscular disease or neuropathy as a result of trauma/injury
- Combative patients or any scenario where the block cannot be performed safely
- Signs of infection overlying injection site
Equipment
- Order in Apex (medications are not stocked in block cart):
Ropivacaine 0.2% 40cc OR Ropivacaine 0.5% 20cc + NS 20cc
Lidocaine 1% 10cc (for skin infiltration)
- Point-of-care ultrasound with high-frequency linear transducer
- From block cart:
Block needle
20cc syringe x 2, 3-way stop-cock
Needles/syringes for drawing up meds and performing skin infiltration
- Chlorhexidine swab
Ultrasound probe cover
Sterile gloves
Local Anesthetic Systemic Toxicity
Protocol based on American Society for Regional Anesthesia and Pain Medicine: Checklist for Treatment of Local Anesthetic Systemic Toxicity
- Call for Code Team.
- Ventilate with 100% oxygen; prepare for intubation.
- Administer benzodiazepines for seizure activity.
- Initiate ACLS, if necessary.
AVOID vasopressin, calcium channel blockers, beta-blockers, or local anesthetic
REDUCE individual epinephrine doses to <1 mcg/kg - Administer 20% lipid emulsion therapy (Intralipid 20%).
- 1.5 cc/kg bolus over 1 min, followed by 0.25 cc/kg/min infusion
Repeat bolus every 5 min if hemodynamic instability persists; max 3 doses - May increase infusion to 0.5 cc/kg/min (max 10 cc/kg in first 30 mins of treatment)
- Continue infusion for at least 10 mins after return of hemodynamic stability
Additional considerations:
- Consider ECMO/cardiopulmonary bypass
- Prolonged CPR (>60 min) may be necessary
- AVOID: propofol, vasopressin, calcium channel blockers, beta-blockers, and lidocaine
- Consider amiodarone first line for arrhythmias
- After resuscitation, transfer patients to ICU for observation