**5. Peripheral nerve blockade for perioperative pain**

As explained above, the hip capsule is mainly innervated by the articular branches of the femoral and obturator nerve.

Blockade of the femoral, obturator and lateral cutaneous nerve of the thigh may be sufficient for perioperative analgesia for extracapsular fractures and some intracapsular fractures in trauma surgery.

When considering regional anaesthesia for hip surgery and pain management, there are several different approaches, such as lumbar plexus block/ psoas sheath block, lumbar plexus block/psoas compartment block, lumbar paravertebral block, femoral nerve block, superior gluteal nerve block/sciatic nerve block, spinal and epidural anaesthesia [23–26].

A very reliable method of blocking all three is the psoas compartment block, although this risks a degree of neuraxial blockade and formation of a deep haematoma in recently anticoagulated patients.

Anterior approaches (femoral nerve blockade/fascia iliaca compartment block) do not block all three nerves, but reduce post-operative analgesia requirement, and are more suitable to ultrasound-guided placement and continuous catheter infusions post-operatively. Moreover, in few studies, authors and their colleagues evaluated

that especially fascia iliaca compartment block is simple to perform, requires minimal training and also is an effective substitute for conventional treatment of pain in elderly patients with hip fractures. Fascia iliaca compartment block is starting to be used as a routine technique for clinically diagnose hip fracture in the emergency room in various clinical centres in Europe [3].

#### **5.1 Performing the fascia iliaca compartment block (FICB)**

The fascia iliaca compartment is a virtual space anteriorly limited by the posterior surface of the fascia iliaca, posteriorly by the iliacus muscle, and is cranially in continuation with the space between quadratus lumborum muscle and its fascia. Three important nerves for hip innervation and sensory innervation of the thigh are located in this space, the femoral nerve, obturator nerve and lateral femoral cutaneous nerve. Lateral femoral cutaneous nerve is a merely sensory nerve originating from the lumbar plexus (L2–L3), emerging from the lateral side of the psoas major muscle and crossing the iliacus muscle obliquely, continuing towards anterior superior iliac spine and passing under the inguinal ligament through the lacuna musculorum. It then divides into anterior branch responsible for sensory innervation of the anterior and lateral thigh as far as the knee, and posterior branch that passes backwards and innervates the skin superior to the greater trochanter down to the middle of the thigh. Additionally, the obturator nerve crosses through the psoas muscle and can be variably blocked by this type of approach. Landmarks for orientation when performing FICB are the anterior superior iliac spine and the pubic tubercle (inguinal ligament). When performing the infra-inguinal approach, this area is divided into thirds, and the injection site is located 1–2 centimetres below the inguinal ligament between the lateral and middle third. It can be performed without ultrasound guidance. When performing without ultrasound guidance, a characteristic '2 pops' are felt that indicate access into the compartment. A study reported an increased frequency of sensory loss in the medial aspect of the thigh when using ultrasound-guided FICB. Similarly, ultrasound guidance increased the frequency of femoral and obturator motor block. Literature also depicts a supra-inguinal ultrasound-guided approach [23]. A supra-inguinal FICB produces a more complete sensory block of the medial, anterior and lateral region of the thigh when compared to infra-inguinal FICB. Likewise, supra-inguinal FICB leads to a more consistent spread in the cranial direction, thus spreading the anaesthetic more consistently towards the lumbar plexus and three targeted nerves. Authors suggest that a sufficient volume to reach femoral nerve, obturator nerve and lateral femoral cutaneous nerve using FICB should be 40 mL. However, the supra-inguinal approach has a superior post-operative analgesic efficacy compared with infra-inguinal approach along with significantly less morphine consumption in the first 24 hours following total hip arthroplasty. **Figure 3a** and **3b** show positioning and longitudinal imaging for ultrasound guided proximal FICB, an in plane approach. Absolute contraindications for this technique are patient's unwillingness to consent to the procedure, known allergy to local anaesthetics, local anaesthetic injection, which has already approached the maximum dosage, previous femoral bypass surgery or close positioning of a graft, local infection at the injection site and relative contraindications are use of anticoagulant therapy with INR >1.5, with need for consideration of recent clopidogrel/high-dose aspirin/low-molecular-weight heparin consumption.

Studies report on paramedics performing FICB on patients with suspected hip fracture at the scene of injury as well [24]. A systematic review on efficacy of prehospital analgesia with FICB for femoral fractures concluded that FICB is suitable for use in the prehospital environment for pain management, with few adverse effects, and can be performed with a high success rate by practitioners of any background. FICB proved to provide superior

#### **Figure 3.**

*(a) Positioning for ultrasound guided proximal FICB. In plane approach with longitudinal (coronal) imaging. (3b) Longitudinal imaging for ultrasound guided fascia iliaca block.*

analgesia compared to intravenous use of fentanyl before positioning patients for spinal anaesthesia when undergoing surgery for femoral neck fractures of all types. Also, FICB reduced morphine requirement preoperatively for patients with femoral neck fractures, which can be indicated for hip arthroplasty, hip arthroscopy and burn management of the region innervated by nerves blocked by FICB as well. A study reports on reduced morphine consumption after total hip arthroplasty when a longitudinal high-dose suprainguinal fascia iliaca compartment block was used. Furthermore, continuous femoral block was compared with FICB in patients undergoing hip arthroplasty, and it was concluded that both techniques have equivalent post-operative analgesic efficacy without any difference in functional outcome. Additionally, it was concluded that the fascia iliaca compartment catheter can be placed more quickly than the femoral nerve catheter, but the onset time of sensory and motor blockade is longer when performing the FICB.

#### **5.2 Critical evaluation of quadratus lumborum block**

Quadratus lumborum block (QLB), referred to as the 'interfascial plane block', was first described in 2007 as a block of the posterior abdominal wall performed exclusively under ultrasound guidance. It was defined as a variant of a transversus abdominis plane block for a wider analgesia distribution and long-lasting post-operative analgesia. Thoracolumbar fascia (TLF) embeds a thick network of sympathetic neurons and plays an important role in QLB analgesia. However, the true mechanism of analgesia of the QLB is not yet clarified. Local spread of anaesthetics along the TLF is assumed to be accountable for part of the analgesia. Literature describes four different types of QLB depending on the needle tip positioning in relation to QL muscle—anterior, posterior, lateral and intramuscular QLB. In anterior QLB, local anaesthetic is applied in front of the QL muscle, at the level of its attachment to the transverse process of the L4 vertebra. In intramuscular QLB, local anaesthetic is applied directly into QL muscle.

When considering hip surgery and post-operative management, the anterior QLB may play a role in analgesia. It can be performed in a manner that the patient is placed into a lateral position with the needle inserted through the QL in an anteromedial direction. QLB 3—anterior/transmuscular: LA applied in front of the QL muscle, at the level of insertion—transverse process of L4 vertebra.

*Regional Anaesthesia for Hip Surgeries DOI: http://dx.doi.org/10.5772/intechopen.104086*

#### **Figure 4.**

*Scanning technique to identify QL, PM and erector spinae muscles at the level of transverse process (TP) with correaltin ultrasound image on the right.*

The local anaesthetic is injected between the QL muscle and psoas major muscle under ultrasound guidance with dosage in the range of 0.2 to 0.4 ml/kg of 0.2 to 0.5% ropivacaine or 0.1 to 0.25% bupivacaine per side is recommended, minimum 15 mL of solution, and one must be aware on highly vascular region [27]. **Figure 4** shows the scanning technique to identify QL, PM and erector spinae muscles at the level of transverse process (TP) with correlating ultrasound image on the right.

Few cases have shown QLB to be beneficial in the management of proximal femoral fractures in high-risk geriatric patients and a patient that underwent hemiarthroplasty after a femoral neck fracture. Few studies also suggest that QLB might provide similar analgesia in comparison with lumbar plexus block for total hip arthroplasty. A role for QLB is in multimodal pain management for hip surgery patients due to its potential for analgesic effectiveness and preservation of muscle strength, which makes it less likely to impair early functional rehabilitation. To summarise, QLB has shown potential for use in hip surgery perioperative pain management, but still lacks sufficient data from prospective studies to be accepted as a reliable treatment approach. Pre- or post-operative peripheral nerve blockade may be used to supplement either general or spinal anaesthesia.

### **6. Monitoring**

Minimum standards for monitoring during the surgery include the continuous presence of the anaesthetist, pulse oximetry, capnography, electrocardiography ECG and non-invasive blood pressure monitoring. Core temperature monitoring should be used routinely. Further monitoring equipment such as invasive blood pressure monitoring, central venous pressure (CVP), cardiac output, bispectral index (BlS) and cerebral oxygen saturation depends of patient's comorbidities.

### **7. Supplemental pain relief**

Regular paracetamol administration should continue throughout the perioperative period. Non-steroidal anti-inflammatory drugs should be used with extreme caution

in hip fracture patients and are contraindicated in those with renal dysfunction. Similarly, opioids (and tramadol) should be used with caution in patients with renal dysfunction: oral opioids should be avoided, and both, dose and frequency of intravenous opioids should be reduced (e.g. halved). Codeine should not be administered, as it is constipating, emetic and associated with perioperative cognitive dysfunction.
