Postoperative analgesia after:
– hip surgery
– anterior thigh surgery
– knee surgery
Only when a femoral nerve block and/or a lateral femoral cutaneous nerve block is not feasible
1 – Indications
UGRAbas
2 – Anatomy of the fascia iliaca compartment
The fascia iliaca is the muscle fascia of the iliacus muscle and is continuous with the fascia of the psoas major muscle
Laterally it is attached to the iliac crest
The femoral as well as the lateral femoral cutaneous nerves are located underneath the fascia iliaca
The idea of the fascia iliaca block is to inject a large volume of local anaesthetic midways between the femoral and lateral femoral cutaneous nerves in order to obtain lateral and medial spread that will cover both nerves
4 – Sonoanatomy of the fascia iliaca compartment block
The needle is advanced through the fascia lata and the iliaca fascia – but not into the muscle
Local anaesthetic is injected into the fascial plane between the iliaca fascia and the muscle
3 – Scanning technique for the fascia iliaca compartment block
– Place the patient supine
– Place the high-frequency linear probe in the femoral crease, lateral to the femoral artery
– Identify the femoral artery, the iliopsoas muscle, the fascia iliaca, and the sartorius muscle by sliding lateral (see next page)
– Insert the needle from the lateral end of the probe with in-plane technique and pierce the fascia iliaca (usually with a palpable “pop”
– Inject local anaesthetic with visible spread between the muscle and the fascia iliaca without resistance and no pain
4 – Scanning technique for the ultrasound guided rectus sheath block
– Place the patient supine
– Place the high-frequency linear probe with the medial end just on top of the linea alba
– Visualize the linea alba, the rectus abdominis, and the posterior rectus sheath (see next page)
– Use color Doppler to identify the epigastric arteries
– Advance the needle through the rectus abdominis muscle until the needle tip enters the space between the belly of the muscle and the posterior layer of the rectus sheath
– Inject 10 mL of local anaesthetic per side in adults. In children 0.5 mg ropivacaine/kg can be injected per side
5 – Sonoanatomy of the rectus sheath block
The needle is advanced to the fascial plane between the muscle fascia of the rectus abdominis and the posterior layer of the rectus sheath (see picture)
1 – Indications
– Midline incisions near the umbilicus
– Midline trocar holes near the umbilicus
– Umbilical surgery
2 – Anatomy of the rectus sheath
The rectus sheath is made by the anterior aponeuroses of the lateral abdominal muscles (external and internal obliques and the transverse abdominis) that split into an anterior and a posterior layer that encloses the rectus abdominis muscle on each side; the two layers fuse on the medial side of the rectus muscle and attach to the linea alba
The anterior layer of the rectus sheath extends from the xiphoid process to the pubic symphysis
The posterior layer only extends 3-5 cm below the umbilicus to the socalled arcuate line and it is separated from the peritoneum by the transversalis fascia
The 9th, 10th, and 11th intercostal nerves and the epigastric blood vessels are sandwiched between the rectus abdominis muscle fascia and the posterior layer of the rectus sheath
Blockade of these nerves with a rectus sheath block produces periumbilical anaesthesia
3 – Anatomy: The rectus abdominis muscle
The tendinous inscriptions of the rectus abdominis muscle are not attached to the posterior lamina of the rectus sheath
This means that local anaesthetic injected between the rectus abdominis muscle and the posterior lamina in theory can spread along the backside of the rectus abdominis muscle and anaesthetize the anterior cutaneous branches of the 9th, 10th and 11th intercostal nerves
9 – Sonoanatomy of the deep peroneal nerve in the anterior compartment
The deep peroneal nerve can be blocked with ultrasound guidance 5-10 cm proximal to the ankel, where the target runs adjacent to the anterior tibial artery sandwiched between the muscles of the anterior compartment and the interosseous membrane