FEMORAL NERVE BLOCK'.pptx

Femoral nerve block.
Indications,Anatomy,Techniques,USG LAndmark PNS COmplications

1. FEMORAL NERVE BLOCK. DR.MRUNMAYAI JADHAV MODERATOR:DR SUMITRA BAKSHI

2. INTRODUCTION The femoral nerve block is one of the most clinically applicable nerve block techniques that it is relatively simple to perform, carries a low risk of complications, and results in a high success rate. 2

3. I NDICATION S 1. Procedures on anterior thigh (i.e. Lacerations, skin graft, muscle biopsy) 2. Pin or plate insertion /removal (femur) 3. Femur fractures 4. Analgesia/Anaesthesia for knee arthroscopy. 5. TKA as a part of multimodal regimes. 6. Completer lower limb anaesthesia if combined with sciatic nerve bloc 3

4. ANATOMY Femoral nerve is motor and sensory nerve. It is derived from posterior division of ventral rami of L2-L4 within psoas major muscle. It descends in the grove between psoas and iliacus muscle and enters the thigh by passing beneath inguinal ligament lateral to femoral artery. The femoral nerve lies outside femoral sheath and is covered by two fascial layers,Fascia lata and Fascia iliaca . Nerve divides into anterior and posterior branches.The anterior branches are primarily cutaneous and deeper branches are motor 4

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6. 6 DERMATOMES MYOTOMES OSTEOTOMES Skin over Anteromedial aspect of thigh and knee Medial border of leg and medial malleolus (via saphenous nerve Sartorius Quadriceps femoris (rectus femoris, vastus lateralis, vastus intermedius, vastus medialis) Iliopsoas Pectineus Anterior wall of the hip joint Anterior aspect of the femur Anteromedial walls of the knee joint. DISTRIBUTION OF ANESTHESIA

7. DISTRIBUTION OF ANESTHESIA 7 Femoral nerve block results in anesthesia of the anterior and medial thigh down to and including the knee, as well as a variable strip of skin on the medial leg and foot. It also innervates the hip, knee, and ankle joints.

8. 8 POSITION AND TECHNIQUES Position of the patient is supine with affected limb abducted and externally rotated. Varioius techniques that can be used for administering this block include: Ultrasound guided with or without use of peripheral nerve stimulator Landmark technique

9. 9 EQUIPMENTS REQUIRED T he equipment recommended for a femoral nerve block includes the following: Ultrasound machine with linear transducer (8–18 MHz), sterile sleeve, and gel Standard nerve block tray One 20-mL syringe containing local anesthetic A 50- to 100-mm, 22-gauge, short-bevel, insulated stimulating needle Peripheral nerve stimulator

10. ULTRASOUND GUIDED 10 Under all aseptic precaution a high-frequency linear ultrasound transducer is placed over the area of the inguinal crease parallel to the crease itself, or slightly more transverse

11. SONOANATOMY 11

12. 12 TECHNIQUE Femoral nerve is identified. The needle is inserted in-plane in a lateral to medial orientation and advanced toward the femoral nerve

13. 13 The needle pierces the fascia iliaca lateral to the femoral nerve (FN) and the needle tip is advanced along the deep border of the nerve . Once the needle tip is adjacent (either above, below, or lateral) to the nerve and after careful aspiration, 1–2 mL of local anesthetic or saline is injected to confirm proper needle placement Proper injection will push the femoral nerve away from the injection.

14. 14 LANDMARK TECHNIQUE T he site of needle insertion is located at the femoral crease but below the inguinal crease and immediately lateral (1 cm) to the pulse of the femoral artery The needle is advanced through the fascia lata and iliaca , often associated with a certain feeling of a “pop” as the needle pierces the fasciae. 

15. 15 STIMULATION AND INJECTION TECHNIQUE Starting with desired initial current of 1-2 mA with pulse duration of 0.1 sec and frequency of 1-2Hz,gradually advance the needle and reduce the current. Motor response of quadriceps muscle group is obtained at 0.2 to 0.5 mA After negative aspiration 1-2ml of LA is injected which will abolish the response due to displacement of the nerve away from the needle tip and change in conduction properties of the nerve due to LA. Following this the current is increased to the initial level and if no muscle stimulation is seen then the remaining drug is injected. INTRANEURAL INJECTION Failure of twitch to disappear or motor response with low intensity current of less than 0.2mA Pain on injection High injection pressure

16. 16 RESPONSE OBTAINED INTERPRETATION PROBLEM ACTION No response The needle is inserted either too medially or to laterally Femoral artery not properly localized Reinsertion of the needle  Bone contact The needle contacts hip or superior ramus of the pubic bone The needle is inserted too deep Withdraw to the level of the skin and reinsert in another direction Local twitch Direct stimulation of the illiopsoas or pectineus muscle Too deep insertion Withdraw to the level of the skin and re-insert in another direction Vascular puncture Needle placement into the femoral or femoral circumflex artery, less commonly - femoral vein Too medial needle placement Withdraw and reinsert laterally 1 cm Patella twitch Stimulation of the main trunk of the femoral nerve None Accept and inject local anesthetic

17. CONTINIOUS FEMORAL NERVE BLOCK 17 The continuous technique is similar to the single-injection technique. After passage through both fascia lata and iliaca , the needle is advanced to elicit a patellar twitch using a current output between 0.3 and 0.5 mA (0.1 msec) The catheter is then inserted 5 cm beyond the tip of the needle and secured in place. After a negative aspiration test for blood, a bolus dose of 10 mL of local anesthetic is injected and followed by a continuous infusion of dilute local anesthetic and/or intermittent boluses of 5 mL hourly. Catheter insertion under the fascia iliaca should be without resistance.

18. 18 COMPLICATIONS 1. HEMATOMA When the femoral artery or vein is punctured, the procedure should be stopped and pressure applied over the puncture site for 2–3 min 2.NERVE INJURY Use a nerve stimulator avoid injection when motor response is present at <0.3 Ma. Do not inject when high pressures on injection are encountered. Abort injecting the drug if there is severe pain on injection Use the minimal efficient volume and concentration of local anesthetic (15-20 mL) 3.CATHETAR INFECTION Use strict aseptic technique during catheter insertion. Sterile drapes should be used with continuous techniques. Remove the catheter after 48–72 h (risk of infection increases with time).

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