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Soli Deo Gloria . Femoral Nerve Blocks and 3-in-1 Nerve Blocks. Developing Countries Regional Anesthesia Lecture Series Daniel D. Moos CRNA, Ed.D . U.S.A. [email protected] Lecture 17. Disclaimer.

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Femoral nerve blocks and 3 in 1 nerve blocks l.jpg

Soli Deo Gloria

Femoral Nerve Blocks and3-in-1 Nerve Blocks

Developing Countries Regional Anesthesia Lecture Series

Daniel D. Moos CRNA, Ed.D. U.S.A. [email protected]

Lecture 17


Disclaimer l.jpg
Disclaimer

  • Every effort was made to ensure that material and information contained in this presentation are correct and up-to-date. The author can not accept liability/responsibility from errors that may occur from the use of this information. It is up to each clinician to ensure that they provide safe anesthetic care to their patients.


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Introduction

  • Currently underutilized for clinical anesthesia and postoperative pain management.

  • Lower extremity peripheral nerve blocks have historically been performed less frequently than peripheral nerve blocks of the upper extremities.


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3-in-1 Block

  • Suppose to block the femoral nerve, lateral femoral cutaneous nerve, and obturator.


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Indications for FNB/3-in-1 Block

  • Operations of anterior thigh (lacerations, skin grafts, muscle biopsy)

  • Pin or plate insertion at the upper femur

  • Femur fractures

  • Analgesia of hip (dislocations, femoral nerve fractures)

  • Analgesia of the knee


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Limitations- Knee

  • Not complete analgesia of the knee. The knee is innervated by the femoral, obturator, and sciatic nerve.

  • These blocks will create a motor block of the quadriceps.


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Limitations- Hip

  • Hip is innervated by the femoral, obturator, and lateral femoral cutaneous nerve.

  • A small contribution comes from the sciatic but should not be significant.


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Anatomy

  • The femoral nerve is the largest branch of the lumbar plexus.

  • Femoral nerve is created from contributions from L2, L3, and L4.

  • The femoral nerve enters into the thigh under the inguinal ligament, between the psoas and iliacus mucle.



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Anatomy

Skin

Femoral Artery

Fascia lata

Femoral Vein

Femoral Nerve

Fascia iliaca

Iliopsoas muscle

Pectineous muscle



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Femoral Nerve “sheath”

  • Contains the femoral nerve and artery

  • It is located between the psoas and iliacus muscle.

  • It is located below the fascia iliaca.


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Lateral Femoral Cutaneous Nerve and Obturator Nerves

  • Lateral femoral cutaneous nerve is formed by contributions from L2 and L3

  • Obturator nerve is formed by contributions from L2, L3, and L4


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Innervations

  • Femoral Nerve: anterior and medial portion of the thigh (sartorious, pectineus, quadriceps); cutaneous portion of medial and lateral thigh; periosteum of the femur. The posterior division of the femoral nerve will become the saphenous nerve.

  • LFCN: purely sensory to lateral buttock, thigh, and knee joint.

  • Obturator Nerve: sensory to medial thigh, hip joint, and adductor muscles.



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Contraindications

  • Burn or infection at the injection site

  • Coagulopathy

  • Vascular graft

  • Neurological disease (relative)

  • Patient refusal

  • Local anesthetic allergy


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Technique

  • Same for either block

  • Locate the anterior superior iliac spine and the pubic tubercle. A line between these two structures is where the inguinal ligament is located.

  • Just below this line is the femoral nerve.


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Technique

  • Palpate the femoral artery

  • The femoral nerve should be located 1 cm lateral to the palpation.

  • Medial to lateral the structures are femoral vein, artery, and nerve.


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Technique

  • For paresthesia technique a blunted needle should be used.

  • Insert perpendicular while aspirating for blood

  • Once paresthesia is elicited pull back slightly and inject. There should be no pain.

  • If you are at a depth of 4-5 cm pull back and start over.

  • As with any peripheral nerve block frequent aspiration is mandatory.


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Technique 2 pop technique

  • Blunted needle

  • A slight increase in resistance followed by a loss of resistance indicates that you have transversed the fascia lata.

  • A second increase in resistance followed by a loss of resistance indicates that you have transversed fascia iliaca.

  • Deposit local anesthetic. (aspirate, make sure no pain, etc.)


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Technique Nerve Stimulator

  • 2 inch, 22 gauge needle (insulated)

  • 2 cm lateral to femoral pulse, 2 cm down from inguinal ligament.

  • Identify quadriceps contraction

  • Reduce stimulation to 0.5 mA and adjust needle for continued quad contraction.

  • Injection of 1 ml of local anesthetic should see the contractions start to fade.


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Local Anesthetics

  • FNB = 15-20 ml of local

  • 3-in-1 NB = 25-30 ml of local

  • Use 1:200,000 epi containing solutions or add yourself.

  • 1-2% lidocaine will have an onset of 10-20 minutes and last 2-5 hours for anesthesia; up to 8 hours for analgesia.

  • Bupivacaine will have an onset of 15-30 minutes and last up to 5-15 hours for anesthesia and up to 30 hours for analgesia


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Complications

  • Intravascular injection

  • Local anesthetic toxicity

  • Nerve trauma

  • Prolonged motor blockade of the muscles of the thigh

  • Hematoma formation

  • Block failure


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Differences between FNB and 3-in-1 Nerve Block

  • Volume: 20 ml or less for FNB; 25-30 ml of 3-in-1 Nerve Block

  • More volume = more spread

  • Pressure applied distally to the injection site will help the spread of local anesthetic further up to the lateral femoral cutaneous nerve and LFCN.


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Controversy

  • Studies have found that the 3-in-1 nerve block inconsistently blocks the obturator nerve (4%-78%) depending on volume (up to 40 ml).

  • Most likely the 3-in-1 nerve block will consistently block the FN and LFCN


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Controversy “Is there really a sheath”

  • Cadaver studies have found no conclusive evidence that there is a femoral sheath.


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References

  • Burkard J, Lee Olson R., Vacchiano CA. Regional Anesthesia. In Nurse Anesthesia 3rd edition. Nagelhout, JJ & Zaglaniczny KL ed. Pages 977-1030.

  • Morgan, G.E. & Mikhail, M. (2006). Peripheral nerve blocks. In G.E. Morgan et al Clinical Anesthesiology, 4th edition. New York: Lange Medical Books.

  • Moos, D.D. & Cuddeford, J.D. (1998). AANA Journal Course for nurse anesthetists- Femoral nerve block and 3-in-1 nerve block in anesthesia. AANA Journal volume 66; issue 4.

  • Wedel, D.J. & Horlocker, T.T. Nerve blocks. In Miller’s Anesthesia 6thedtion. Miller, RD ed.Pages 1685-1715. Elsevier, Philadelphia, Penn. 2005.

  • Wedel, D.J. & Horlocker, T.T. (2008). Peripheral nerve blocks. In D.E. Longnecker et al (eds) Anesthesiology. New York: McGraw-Hill Medical.


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