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FEMORAL NERVE BLOCKS AND 3-IN-1 NERVE BLOCKS Soli Deo Gloria Developing Countries Regional Anesthesia Lecture Series Daniel D. Moos CRNA, Ed.D. U.S.A.

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1 FEMORAL NERVE BLOCKS AND 3-IN-1 NERVE BLOCKS Soli Deo Gloria Developing Countries Regional Anesthesia Lecture Series Daniel D. Moos CRNA, Ed.D. U.S.A. Lecture 17

2 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.

3 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.

4 3-in-1 Block  Suppose to block the femoral nerve, lateral femoral cutaneous nerve, and obturator.

5 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

6 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.

7 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.

8 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.

9 Femoral Triangle

10 Anatomy Pectineous muscle Iliopsoas muscle Fascia iliaca Fascia lata Skin Femoral Vein Femoral Artery Femoral Nerve

11 Anatomy

12 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.

13 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

14 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.

15 Anatomy

16 Contraindications  Burn or infection at the injection site  Coagulopathy  Vascular graft  Neurological disease (relative)  Patient refusal  Local anesthetic allergy

17 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.

18 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.

19 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.

20 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.)

21 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.

22 Local Anesthetics  FNB = ml of local  3-in-1 NB = ml of local  Use 1:200,000 epi containing solutions or add yourself.  1-2% lidocaine will have an onset of minutes and last 2-5 hours for anesthesia; up to 8 hours for analgesia.  Bupivacaine will have an onset of minutes and last up to 5-15 hours for anesthesia and up to 30 hours for analgesia

23 Complications  Intravascular injection  Local anesthetic toxicity  Nerve trauma  Prolonged motor blockade of the muscles of the thigh  Hematoma formation  Block failure

24 Differences between FNB and 3-in-1 Nerve Block  Volume: 20 ml or less for FNB; 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.

25 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

26 Controversy “Is there really a sheath”  Cadaver studies have found no conclusive evidence that there is a femoral sheath.

27 References  Burkard J, Lee Olson R., Vacchiano CA. Regional Anesthesia. In Nurse Anesthesia 3 rd edition. Nagelhout, JJ & Zaglaniczny KL ed. Pages  Morgan, G.E. & Mikhail, M. (2006). Peripheral nerve blocks. In G.E. Morgan et al Clinical Anesthesiology, 4 th 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 6 th edtion. Miller, RD ed. Pages Elsevier, Philadelphia, Penn  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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