Anesth Analg 2004;98:1077-81
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000105863.04140.AE
PAIN MEDICINE
The Efficacy of Continuous Fascia Iliaca Compartment Block for Pain Management in Burn Patients Undergoing Skin Grafting Procedures
Olivier Cuignet, MD*,
Jean Pirson, MD*,
Jenna Boughrouph, MD
, and
Diane Duville, FRCC*
*Burn Center, Queen Astrid Military Hospital, Military Medical Research Program and Development Committee, Brussels, Belgium, and the
Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
Address correspondence and reprint requests to Olivier Cuignet, MD, Burn Center, Hopital Militaire Reine Astrid, Rue Bruyn 2, 1120 Brussels, Belgium. Address email to Olivier.Cuignet{at}smd.be
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Abstract
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Postoperative pain from split skin donor sites is often more intense than the pain at the grafted site. In this prospective, randomized, double-blind study we assessed the efficacy of a continuous fascia iliaca compartment block (FICB) in reducing the pain at the thigh donor site. Twenty patients, with a total burn surface area of 16% ± 13% (mean ± SD) were randomized 1:1 to receive either ropivacaine 0.2% or saline 0.9%. All patients received a general anesthesic followed by preincision continuous FICB with 40 mL of the randomized solution, then an infusion of 10 mL/h of either ropivacaine or saline until the first dressing change (72 h later). Postoperative analgesia consisted of propacetamol 2g/6h, IV patient-controlled analgesia of morphine chlorhydrate (2 mg/mL), and morphine hydrochlorate 0.5 mg/kg PO once 60 min before first dressing change. The visual analog scale (VAS) scores were compared using the Mann-Whitney U-test preoperatively, 24 and 48 h postoperatively, and during the first dressing change. The cumulative morphine consumption was compared with repeated-measures analysis of variance followed by Scheffé’s method if indicated. Patients with continuous FICB had significantly reduced postoperative morphine consumption at all time points (23 ± 20 versus 88 ± 29 mg after 72 h, study versus control groups, respectively; P < 0.05). In both groups, VAS scores remained low but were only significantly lower for patients with continuous FICB during the first dressing change (3 [1] versus 7 [3]; median [interquartile range]; P < 0.05). We conclude that continuous FICB is an efficient method for diminishing pain at the thigh donor site. (250 words)
IMPLICATIONS:Postoperative pain at the split skin donor sites is often more intense than the pain at the grafted site. This prospective, randomized, double-blind study assessed the efficacy of a continuous fascia iliaca compartment block in reducing the pain at the thigh donor site.
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Introduction
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Burn patients who have undergone split skin grafting often have more pain at the donor site than at the grafted site, especially during dressing changes (1). Despite their side effects, opioids are still the main means of providing adequate analgesia in these patients (2). To reduce the need for supplemental opioids, various ways of alleviating the pain at skin graft donor sites have been reported. The development of an optimal skin graft donor site dressing (3), infiltration of subcutaneous bupivacaine (4), and application of topical lidocaine at the donor site (5) have all proved effective. However, these strategies do not last longer than 24 h and therefore do not provide adequate pain relief for the first dressing change. At our institution, skin graft harvest sites are usually chosen at the lateral and/or medial upper part of the thigh for both functional and esthetic reasons. These cutaneous areas of surgical incision coincide with the distribution systems of the lateral femoral and the femoral nerve. The fascia iliaca compartment block (FICB) was first described by Dalens et al. (6) and is a modification of the "3 in 1" femoral block described by Winnie et al. (7). It is effective in producing simultaneous blockade of both the cutaneous lateral femoral and femoral nerves in adults. Continuous FICB with bupivacaine 0.2% over 48 h reduced opioid requirement in the postoperative period after lower limb orthopedic surgery (8). In this study, we analyzed the efficacy of this technique for donor site pain of the thigh for 3 days postoperatively until the first dressing change. We substituted bupivacaine 0.2% with ropivacaine 0.2% because of its reduced toxicity.
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Methods
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Twenty adult burn patients (male and female) aged between 18 and 80 yr were enrolled into the study. The patients had a total burn surface area (TBSA) of 16% ± 13% (mean ± SD) and were scheduled for unilateral split skin graft harvest of the thigh. Written informed consent was obtained from each patient before enrollment; the study was approved by our institutional Ethics Committee. Exclusion criteria were significant medical or psychiatric problems, a perceived inability to cooperate with the study protocol, lower limb vascular problem, morphine consumption on a regular basis for more than 2 days, or a history of allergy to local anesthetics or morphine. Patients were randomized (1:1) to receive, via the femoral catheter, either ropivacaine 0.2% (study group) or saline 0.9% (control group).
All patients were premedicated with oral morphine 0.5 mg/kg 90 min before surgery, for preoperative dressing care. General anesthesia was induced with sufentanil 0.3 µg/kg, propofol 2 mg/kg, and rocuronium 0.6 mg/kg and maintained with 1 MAC of sevoflurane in O2/N2O. Immediately before surgery, the FICB was initiated using a bullet-tipped needle and catheter (Contiplex A®, Braun-Melsungen AG, Mesulgen, Germany); a "double pop" technique was used to enter the fascia iliaca at the medial border of the sartorius muscle. The cannula was advanced at least 5 cm cranially, the sheath was distended with 40 mL of the randomized solution, and then an 18-gauge styletted catheter was advanced 
13 cm cranially through this cannula. Once the catheter was secured, a continuous infusion of either the study drug or the saline solution was started at a rate of 10 mL/h at the same time as the surgical incision was made. This incision occurred within 30 min after the FICB was initiated. The infusion was continued for 72 h, until the first dressing change. If systolic blood pressure increased by more than 10%, or heart rate by more than 15%, of the baseline values recorded before surgical incision (after correction for hypovolemia if present), or if physical manifestations of pain (sweat, tears, or flushing) were observed, IV boluses of 5 µg sufentanil were administered every 5 min until the blood pressure or heart rate decreased and/or the physical symptoms improved. Anesthesia was maintained by an anesthesiologist who was blinded as to the treatment group assigned. The day before surgery, the patients were instructed on how to use a patient-controlled analgesia (PCA) device and encouraged to use this to maintain a satisfactory level of pain relief. They were also taught how to describe pain on a visual analog scale (VAS) of 0 to 100 (0 = no pain; 100 = worst pain possible). After completion of surgery patients were taken to the recovery room and the PCA was connected. Boluses of morphine 1 mg IV were titrated until the VAS score remained below 40 mm. The PCA settings were as follows: morphine chlorhydrate 2 mg/mL, 1 mg bolus with a lockout interval of 5 min, and a maximum dose 25 mg/4 h. In addition, all patients received propacetamol 2 g IV every 6 h (the first injection was given 30 min before the end of surgery).
The duration between burn and surgery and the duration of anesthesia were recorded. An independent observer, blinded as to the randomization, evaluated the VAS scores for pain in general and for pain at the donor site three times daily, starting on the evening of surgery and continuing through the first dressing change. Cumulative morphine consumption was assessed at the same times. Motor block was not evaluated objectively; patients were asked about subjective weakness during movement on the first three postoperative days. A physiotherapist blinded as to the randomization group of the patients recorded the range of flexion achieved daily for the first 3 days. The incidence of nausea, vomiting, and itching were also noted. Patients were asked specific questions during these visits to elicit any signs of local anesthetic toxicity. After the first dressing change, patients and nurses in charge of the procedure were asked individually to score their level of satisfaction, as follows: 2 = satisfied; 1 = undecided; 0 = never again.
Data were analyzed using Statview 5.0 (SAS Institute, Research Triangle Park, NC). Differences between the two groups in age, TBSA, numbers of days between burn and surgery, duration of anesthesia and range of pain-free motion of the thigh donor site were compared using Student’s t-test. Discrete values such as sex ratio, excision site, and side effects were compared using a 
2 test. Statistical analysis for PCA morphine consumption was performed using repeated-measures analysis of variance, followed by Scheffé’s method where appropriate. The nonparametric Mann-Whitney U-test was used for comparison of pain scores. A difference was considered significant when P < 0.05.
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Results
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Patient demographics, %TBSA, excision site, time between burn and surgery, and the duration of anesthesia were similar between the two groups (Table 1). Morphine requirements were significantly less in the study group over the whole course of the study. Mean values ± SD for the study versus control groups, respectively, were as follows: 12 ± 8 versus 48 ± 20 mg (postoperative day 1), 16 ± 12 versus 76 ± 26 mg (postoperative Day 2), and 23 ± 20 versus 88 ± 29 mg (before first dressing change) (Fig. 1). The general VAS pain scores and the VAS pain scores specific to the donor site are shown in Figure 2. Although there was a trend for lower general VAS pain scores, overall, they were similar between the groups during the postoperative period. During the first dressing change, however, general VAS pain scores were significantly smaller in the study group: 3 [1] versus 7 [3] (median [interquartile range]) for the study and the control groups, respectively (P < 0.05). Differences in the donor site VAS pain scores were significantly different during the whole study period, in favor of the study group: 0 [1.5] versus 3.5 [1] (postoperative day 1), 0 [2.25] versus 3 [3.25] (postoperative day 2), and 2 [1.5] versus 8 [2.5] (during dressing changes) for the study and the control groups, respectively.
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Figure 1. Mean (± SD) cumulative morphine (mg) requirements in both treatment groups. Study = ropivacaine group (n = 10); control = saline group (n = 10); baseline = preoperatively; J0 = day of surgery at 20 h; J1 = postoperative day 1; J2 = postoperative day 2; J3 08 h = postoperative day 3 before first dressing change. *P < 0.01 between study and control groups.
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Figure 2. A, visual analogue scale (VAS) pain scores in general. B, VAS pain scores related to the donor site. VAS score was 0–100: 0 = no pain, 100 = worst pain possible. Study = ropivacaine group (n = 10); Control = saline group (n = 10); boxes = 25th–75th percentiles; dark line = median; extended bars = 10th–90th percentiles; circles = values outside the this range; baseline = preoperatively; 24 h = first postoperative day; 48 h = second postoperative day; first dressing change = at the end of the dressing change procedure.
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The incidence of opioid-related side effects was similar in both groups. Most of the patients experienced itching, only one patient in the study group had subjective weakness of the thigh muscles in the postoperative period, and no patients experienced local anesthetic toxicity (Table 2). The range of motion achieved preoperatively was similar between the two groups, but the increased range of motion achieved by the patients in the study group had reached statistical significance by the first postoperative day compared with the control group, P < 0.05 (Table 1). Pain-free hip flexion (mean ± SD), normalized to preoperative value, was as follows: 97% ± 22% versus 68% ± 16% (postoperative day 1) and 109% ± 19% versus 79% ± 18% (postoperative day 2) for the study and control groups, respectively. In the study group, 100% of the nurses and 100% of the patients gave a score of "satisfied" after the first dressing change, compared with only 40% of patients and 30% of nurses in the control group.
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Discussion
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In this study, we showed that continuous FCIB was effective in reducing pain after split skin graft harvest procedures. Both the background pain over the whole postoperative period and the procedural pain during the first dressing change, 72 h postoperatively, were diminished.
It might be argued, however, that the levels of pain experienced were similar in both groups (Fig. 2); although there was a trend for lower pain scores in the study group, this was not statistically different when compared with the control group. Furthermore, the subjects in the control group obtained satisfactory pain control without any demonstrated adverse effects from larger opioid use (Figure 1), and morphine PCA has been reported to be efficient in alleviating the pain from burns (10). Decreasing the dose of morphine, an inexpensive drug, may not be sufficient to justify the use of an invasive procedure unless decreased side effects, superior analgesia, or other benefits can be demonstrated.
Our failure to demonstrate any reduction of the morphine side effects in the study group might have been a result of the small number of patients enrolled in this study; larger studies have demonstrated a reduction of morphine side effects when continuous postoperative loco-regional techniques are used (11). The ratings of pain from skin donor sites are often worse than those from concurrent grafted burns. Therefore, the superior analgesia of the donor site, which we were able to demonstrate in the study group, could be important in improving the postoperative well-being of burn patients (Fig. 2). Furthermore, the FICB also provided a superior analgesia during the first dressing change, when patients in both treatment groups received the same dose of morphine usually recommended for procedural pain (12).
Patients in both groups experienced the same frequent incidence of itching, which was already present preoperatively. Itching is commonly observed in burn areas during healing (9). The relatively long time between burn and surgery in these patients (20 days and 14 days in the study and control groups, respectively) resulted in a part of their superficial burns healing spontaneously.
The lateral femoral cutaneous nerve block procedure has already been shown to provide excellent postoperative analgesia for harvesting split skin graft from the thigh (13). However, with this procedure, the donor site is restricted to the lateral aspect of the thigh, and the reported rate of failure is frequent in inexperienced hands. The FCIB provides a rapid and consistent blockade of the lateral femoral cutaneous and femoral nerves in adults (14). The extents of the cutaneous areas affected by the sensory block, both after the initial injection and at the time of the continuous infusion, are important considerations. They include both the lateral and the anterior aspects of the thigh, which allows for larger skin grafting procedures. Sensory block is achieved by the spread of local anesthetic under the fascia iliaca. The technique can be safely used without the need for a nerve stimulator, as it is based on the "double pop" technique and the site of puncture is far from any vascular or nerve elements. Hence, although our number of subjects was small, a larger study may be able to confirm the superiority of this fast, easy and effective block.
Toxicity as a result of systemic absorption might be a concern with the use of a continuous infusion of ropivacaine. In our study, we did not observe either objective signs or subjective complaints of local anesthetic toxicity in any patients. This agrees with previous studies in which a continuous infusion of equivalent doses of bupivacaine for 48 h did not result in toxic plasma concentrations (15). Bupivacaine and ropivacaine are local anesthetics of the amide type that binds to plasma 
-1 glycoproteins. Pharmacological studies in burn patients have demonstrated a parallel increase in these -1 glycoproteins alongside the inflammatory response to the burn injury, which leads to a decrease in the free fraction of local anesthetics and thereby reduces the risk of toxicity (16). Also, the local anesthetic we used (ropivacaine) has been reported to be less toxic than bupivacaine at equivalent doses (17).
Infection is another area of potential concern when a catheter is left in the groin for 72 h. However, in this study we did not observe any signs of local or systemic infection. A previous report of orthopedic patients showed that femoral catheters are associated with a frequent rate of bacterial colonization but no infections after a 2-day infusion (18). However, in light of recent case reports centered on infections of the psoas muscle during continuous FICB (19), one needs to remain aware of this potential complication and detect it as soon as possible.
A local neurological risk or weakness related to a motor block must also be considered (20). Unfortunately, we did not measure motor block. However, only one patient complained of muscle weakness. Time to taking the first step was not monitored in this study, as some of our patients were not allowed to step on the lower limb that had been freshly grafted. Nevertheless, mobilization was easier for the patients with the FICB technique, who had a significantly greater (P < 0.05) pain-free range of motion (Table 1). This is in accordance with what has previously been reported in a study of orthopedic patients (21). This is a clinically useful attribute and may have been a contributory factor to the higher patient satisfaction score reported in the study group.
A limitation of the technique is obviously the size and the location of the donor site on the lateral and medial parts of the thigh. The number of suitable burn candidates who can benefit from this procedure is, therefore, limited to those who require only small to medium split skin grafts; it would of necessity have to exclude those burned on both thighs. In our experience however, a large number of minor to mildly burned patients could benefit from such a block.
To conclude, we successfully achieved analgesia through the use of a continuous FICB in burn patients after limited skin-grafting procedures. Our results are encouraging and confirm that this procedure warrants further study in this situation. In particular, further trials should be conducted in larger cohorts of patients to confirm the safety of this method.
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Accepted for publication October 24, 2003.
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Abstract
Introduction
