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Three Part Question

For [patients presenting to the emergency department with fractured neck of femur], is [Fascia Iliaca Block (FIB) performed using ultrasound guidance more effective than FIB using landmarks alone] at [providing pain relief]?

Clinical Scenario

Fascia iliaca blocks (FIB), first described by Dalens et al in 1989, have become a key method of managing pain in patients with fractured neck of femur.
In your department FIB tend to be performed using a landmark (loss of resistance) technique. However, it has been noted that there have been a number of ineffective blocks recently, leaving patients still in need of opioids to manage their pain.
At clinical governance one of the consultants, a point of care ultrasound enthusiast, suggests that the department should move to performing FIB under ultrasound guidance as he believes they are more likely to succeed. You leave the meeting wondering if he is right.

Search Strategy

Medline via Pubmed and Cochrane searched in June 2021:
(Fascia iliaca) AND [(Ultrasound) OR (sono*) OR (guided)]

Search Outcome

127 papers were identified via Pubmed, and 188 trials and two Cochrane Reviews were found via Cochrane.
Just two papers were deemed relevant, and are included below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Dolan et al 2008 United Kingdom	80 patients undergoing elective hip or knee surgery, randomised to receive a FIB performed by an anaesthetist: - 40 by landmark/loss of resistance (LOR) technique; - 40 by ultrasound (US) guidance. Outcomes were measured at 30 minutes.	Single centre prospective RCT.	Sensory loss to anterior, medial and lateral aspects of thigh	47% with LOR vs 82% with US (P = 0.001)	- All the blocks were performed by a single anaesthetist. - Neither patients nor anaesthetist were blinded, though investigators measuring sensory and motor block were. - Sensory loss and motor block are not patient centred outcomes.
			Femoral nerve motor block	63% with LOR vs 90% with US (P = 0.06)
			Obturator nerve motor block	22% with LOR vs 44 with US (P = 0.033).
Reid et al 2009 Australia	67 patients presenting to a single emergency department (ED) with neck of femur (NOF), femoral shaft or patella fracture, pseudo-randomised to receive a femoral nerve block (FNB) performed by an emergency medicine registrar: - 33 by landmark/LOR technique; - 34 by ultraound (US) guidance. Outcomes were measured before block and at 15 and 60 minutes after.	Single centre prospective unblinded pseudo-RCT	Femoral nerve sensory block at 15 minutes	6% with LOR vs 29% with US (P = 0.029)	- Intracapsular NOF fractures were excluded, while patella fractures were included. - Convenience sampling. - Inadequate blinding. - Sensory loss is not a patient centred outcome. - No significant difference in pain scores. - Use of analgesia inadequately recorded.
			Femoral nerve sensory block at 60 minutes	Significance not achieved
			Mean difference in pain scores at 15 minutes	Significance not achieved
			Mean difference in pain scores at 60 minutes	Significance not achieved

Comment(s)

Dolan et al demonstrated that a single anaesthetist, likely experienced in ultrasound-guided regional anaesthesia, was more likely to achieve sensory and motor blockade when performing FIB with ultrasound in patients undergoing elective hip or knee surgery. However, it is unclear how easily these results can be extrapolated to the emergency department, where clinicians are likely to have less experience of ultrasound-guided regional anaesthesia. Moreover, sensory and motor block are not patient centred outcomes, and data on pain scores and use of analgesia were not collected. Reid et al demonstrated that emergency medicine physicians performing ultrasound guided FNB (a technique similar to ultrasound guided FIB) achieved earlier sensory blockade than with landmark FIB, but did not demonstrate any significant difference in pain scores. Use of analgesia was poorly recorded, and there were several methodological flaws in the study. No papers were identified that directly answered the clinical question as to whether ultrasound guided FIB is superior to landmark guided FIB.

Clinical Bottom Line

While there is sound logic in suggesting that use of ultrasound enhances block success in experienced hands, there is no good quality evidence to support this claim in the emergency department. Use of ultrasound may also carry risks such as needle misplacement and inadvertent intraneural or intravascular injection in those with less experience. Emergency physicians without formal training and regular practice with ultrasound-guided regional anaesthesia should consider using a landmark technique, and be reassured that there is no evidence of worse outcomes.

References

1. Dolan J, Williams A, Murney E, Smith M, Kenny GN Ultrasound Guided Fascia Iliaca Block: A Comparison With the Loss of Resistance Technique Reg Anesth Pain Med. 2008 Nov-Dec;33(6):526-31
2. Reid N, Stella J, Ryan M, Ragg M Use of ultrasound to facilitate accurate femoral nerve block in the emergency department. Emerg Med Australas 2009 Apr;21(2):124-30.