1. Femoral Nerve Block Santhanam Suresh, MD, FAAP
Director of Research, Department of Pediatric Anesthesia
Professor of Anesthesiology and Pediatrics
Northwestern University’s Feinberg School of Medicine
Children’s Memorial Hospital
Chicago, Illinois

2. SKILL COMPONENTS Pre-operative Preparation Strategy of Procedure
Femoral nerve Block
(ultrasound guided)
SKILL COMPONENTS
Pre-operative Preparation
Strategy of Procedure
Preparation
Position
Procedure
1. Needle Placement
2. Injection
3. Monitoring
Clean up
Handling Post-op Adverse Events

3. Preoperative prep: CONSENT
Femoral Nerve Block
(ultrasound guided)
Preoperative prep: CONSENT
Component 1:
Steps:
How to obtain consent.
Check for vascular or associated anomalies
Video – Femoral Block Consent.mov
Dr. Suresh obtaining consent from a family.

4. Preoperative prep: CONSENT
Femoral Nerve Block
(ultrasound guided)
Component 1:
Preoperative prep: CONSENT
Steps:
How to obtain consent.
Check for vascular or associated anomalies
Check patient for any known anatomical anomalies.
Check for: infection, bleeding abnormalities, vascular insufficiencies, propensity for compartment syndrome
(seen above).

5. Strategy of Procedure Component 2: Femoral Nerve Block Steps:
(ultrasound guided)
Component 2:
Strategy of Procedure
Steps:
Choice of equipment
Choice of local anesthetic solution
3. Dose of local by weight
4. Confer with surgeon
Ultrasound guidance vs. nerve stimulation
U/S guidance: Linear array probe; In-Plane approach; Sterile sheath
Nerve Stimulation: Electronic nerve stimulator with capacity from 0.2-
1.5mAmps; Use 1Mhtz; Twitch rate at 0.3/sec
Ultrasound guidance w/ nerve stimulation

6. Strategy of Procedure Component 2:
Femoral Nerve Block
(ultrasound guided)
Component 2:
Strategy of Procedure
Steps:
Choice of equipment
Choice of local anesthetic solution
3. Dose of local by weight
4. Confer with surgeon
Bupivacaine 0.25% w/ 1:200,000 epinephrine:
Dose: 0.2 mL/kg
Inject in incremental doses
U/S imaging of spread of local anesthetic surrounding the nerve

7. Strategy of Procedure Component 2: Weight (kg) Dose (mL) 10 kg 2 mL
Femoral Nerve Block
(ultrasound guided)
Component 2:
Strategy of Procedure
Steps:
Choice of equipment
Choice of local anesthetic solution
3. Dose of local by weight
4. Confer with surgeon
Weight (kg)
Dose (mL)
10 kg
2 mL
15 kg
3 mL
20 kg
4 mL
25 kg
5 mL
30 kg
6 mL
Weight of formula: 0.2mL/kg
Calculate the proper dose by using the weight of the patient in kg.
Maximum dose: 20mL

8. Strategy of Procedure Component 2: Confer with surgeon:
Femoral Nerve Block
(ultrasound guided)
Strategy of Procedure
Component 2:
Steps:
Choice of equipment
Choice of local anesthetic solution
3. Dose of local by weight
4. Confer with surgeon
Confer with surgeon:
Potential loss of quadriceps function for hours with
potential lose of weight bearing
Potential for not being able to recognize compartment
syndrome if present following block.
- Identify site specificity

9. Prepare for block Component 3: Femoral Nerve Block Steps:
(ultrasound guided)
Component 3:
Prepare for block
Steps:
Get materials
Identify surface landmarks
Prep the ultrasound probe
Prep the patient
Materials for procedure:
Bupivacaine 0.25% w/ 1:200,000 epinephrine
Luer Lock (10mL)
Nonstimulating needle
Stimulating needle: 25mm, 50mm, or 70mm (polymatic). Measure depth of
nerve with US to determine the size of the needle.
Chlorhexadine
EKG electrode (for stimulating purposes)
Chloraprep™

10. Prepare for block Component 3: Femoral Nerve Block Steps:
(ultrasound guided)
Component 3:
Prepare for block
Steps:
Get materials
Identify surface landmarks
Prep the ultrasound probe
Prep the patient
Palpate femoral artery below arcuate line. Femoral nerve is located lateral to the femoral artery. Mark the femoral artery.

11. Prepare for block Component 3: Femoral Nerve Block Steps:
(ultrasound guided)
Component 3:
Prepare for block
Steps:
Get materials
Identify surface landmarks
Prep the ultrasound probe
Prep the patient
Videos – UltraSoundPrep.mov, FemoralPrep.mov

12. Prepare for block Component 3: Femoral Nerve Block Steps:
(ultrasound guided)
Component 3:
Prepare for block
Steps:
Get materials
Identify surface landmarks
Prep the ultrasound probe
Prep the patient
Videos – UltraSoundPrep.mov, FemoralPrep.mov
If you are using chlorhexadine make sure that the surface is completely dry prior to needle insertion. 12

13. Patient Position for block
Femoral Nerve Block
(ultrasound guided)
Component 4:
Patient Position for block
Steps:
Supine position
If patient has fractured femur, plan on performing block on transport cart prior to transfer onto the bed.

14. Procedure for block Component 5: Femoral Nerve Block Steps:
(ultrasound guided)
Component 5:
Procedure for block
Steps:
Placement of needle
- Ultrasound
- Needle
Injection
- Attach syringe
- Aspirate
3. Monitoring
- Watch EKG
Video – Femoral.mov
With the probe placed perpendicular to the nerve axis at the level of and parallel to the inguinal crease, the nerve appears lateral to the large, circular, anechoic femoral artery
Color Doppler may be used to identify the pulsating femoral artery and collapsible femoral vein.

15. Procedure for block Component 5: Femoral Nerve Block Steps:
(ultrasound guided)
Component 5:
Procedure for block
Steps:
Placement of needle
- Ultrasound
- Needle
Injection
- Attach syringe
- Aspirate
3. Monitoring
- Watch EKG
Visualize the femoral vein and artery. Femoral artery should be a single vessel before it bifurcates to the profunda femoris. Lateral to the femoral artery laying on top of the iliacus muscle is the fascia iliaca compartment which envelopes the femoral nerve.

16. Procedure for block Component 5: Femoral Nerve Block Steps:
(ultrasound guided)
Component 5:
Procedure for block
Steps:
Placement of needle
- Ultrasound
- Needle
Injection
- Attach syringe
- Aspirate
3. Monitoring
- Watch EKG

17. Procedure for block Component 5:
Femoral Nerve Block
(ultrasound guided)
Component 5:
Procedure for block
Steps:
Placement of needle
- Ultrasound
- Needle
Injection
- Attach syringe
- Aspirate
3. Monitoring
- Watch EKG
Place a needle in an in-plane approach.
Use an in-plane technique which offers the ability to visualize the needle tip as it enters the fascia iliaca.

18. Procedure for block Component 5: Femoral Nerve Block Steps:
(ultrasound guided)
Component 5:
Procedure for block
Steps:
Placement of needle
- Ultrasound
- Needle
Injection
- Attach syringe
- Aspirate
3. Monitoring
- Watch EKG
Video – InjectionandAspiration.mov

19. Procedure for block Component 5: Femoral Nerve Block Steps:
(ultrasound guided)
Component 5:
Procedure for block
Steps:
Placement of needle
- Ultrasound
- Needle
Injection
- Attach syringe
- Aspirate
3. Monitoring
- Watch EKG
Make sure that the needle is attached using the extension and the needle is flushed prior to ultrasound imaging and placement of needle.
Presence of any air in the needle can obliterate the u/s image. Flush the needle prior to injection.

20. Procedure for block Component 5: Femoral Nerve Block Steps:
(ultrasound guided)
Component 5:
Procedure for block
Steps:
Placement of needle
- Ultrasound
- Needle
Injection
- Attach syringe
- Aspirate
3. Monitoring
- Watch EKG
Inject in graduated doses. Make sure the local anesthetic surrounds the nerve. Ensure that the needle is placed inside the fascia iliaca.

21. Procedure for block Component 5: Femoral Nerve Block Steps:
(ultrasound guided)
Component 5:
Procedure for block
Steps:
Placement of needle
- Ultrasound
- Needle
Injection
- Attach syringe
- Aspirate
3. Monitoring
- Watch EKG
When you give the test dose you need to train yourself to look at the EKG for increasing heart rate and blood pressure.
Tip: Prior to every block make sure you have access to intravenous Intralipid (20%) to be used for rescue if cardiovascular collapse occurs.

22. Clean-up after block Component 6: Femoral Nerve Block Steps:
(ultrasound guided)
Component 6:
Clean-up after block
Steps:
Clean area with a towel

23. Handling post-operative adverse events
Femoral Nerve Block
(ultrasound guided)
Component 7:
Handling post-operative adverse events
Steps:
Quadriceps weakness
Lipid Rescue
Did the patient receive crutch instruction before surgery?
Make sure your patients receive instructions regarding weight
bearing and assistance
Block may last up to 30 hours

24. Handling post-operative adverse events
Femoral Nerve Block
(ultrasound guided)
Component 7:
Handling post-operative adverse events
Steps:
Quadriceps weakness
Lipid Rescue
Lipid Rescue:
Lipid Infusion Therapy is an apparently effective treatment for the most devastating complication of regional anesthesia: cardiovascular collapse from local anesthetic overdose. The Lipid Sink Theory explains the effect by postulating that the lipophilic local anesthetics are absorbed into the infused lipid, thus preventing their toxic effect on the tissue. Recent research suggests that there may be another mechanism for effect.
Rx:
“20% Intralipid: 1.5 mL/kg as an initial bolus, followed by 0.25 mL/kg/min for minutes. Bolus could be repeated 1-2 times for persistent asystole. Infusion rate could be increased if the BP declines.