title: Incidence of intraneural needle insertion in ultrasound-guided femoral nerve block: a comparison between the out-of-plane versus the in-plane approaches.
abstract: BACKGROUND
  The optimal method of ultrasound-guided femoral nerve block (in-plane vs. out-of-plane) has not been established. We tested the hypothesis that the incidence of needle-nerve contact may be higher with out-of-plane than with in-plane needle insertion.
  
  
  METHODS
  Forty-four patients with hip fracture (American Society of Anaesthesiologists physical status I-III) were randomized to receive the femoral block with an out-of-plane approach (needle inserted at a 45-60° angle 1cm caudal to the midpoint of the ultrasound probe just above the femoral nerve) or with an in-plane technique (needle inserted 0.2-0.4 cm from the side of the probe lateral to the femoral nerve). Data collected included depth of needle insertion, response to nerve electric stimulation, and distribution of the injected volume in relation to the nerve (anterior vs. posterior, the latter assuming needle-nerve contact). The sensory block onset was tested at 20 min and block recovery and any neurologic symptoms were evaluated at 24h.
  
  
  RESULTS
  The incidence of needle-nerve contact was significantly higher with the out-of-plane approach (14/22 patients [64%]) than with the in-plane approach (2/22 patients [9%]) (p<0.001) (OR=17.5, 95% CI: 4-79). The rate of paraesthesia on crossing the fascia iliaca was similar in the two groups. All blocks uneventfully regressed; and no patient developed neurologic symptoms.
  
  
  CONCLUSIONS
  Under the conditions of our study, needle-nerve contact during femoral nerve block occurs frequently with the out-of-plane approach. An in-plane approach results in an equally effective femoral block and less incidence of needle-nerve contact.
authors: Department of Anaesthesiology, Hospital Clínic, Universitat de Barcelona, Spain.
authors: A
authors: A
authors: Ruiz
authors: Department of Anaesthesiology, Hospital Clínic, Universitat de Barcelona, Spain. Electronic address: xsala@clinic.ub.es.
authors: X
authors: X
authors: Sala-Blanch
authors: Department of Anaesthesiology, Hospital Clínic, Universitat de Barcelona, Spain.
authors: J
authors: J
authors: Martinez-Ocón
authors: Department of Anaesthesiology, Hospital Clínic, Universitat de Barcelona, Spain.
authors: M J
authors: MJ
authors: Carretero
authors: Department of Anaesthesiology, Hospital Clínic, Universitat de Barcelona, Spain.
authors: G
authors: G
authors: Sánchez-Etayo
authors: Department of Anaesthesia, St Luke's - Roosevelt Hospital Center, University Hospital of Columbia University, New York, USA.
authors: A
authors: A
authors: Hadzic
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip; D004568:Electrodiagnosis; D005260:Female; D005267:Femoral Nerve / Q000293:injuries*; D006620:Hip Fractures / Q000601:surgery; D006801:Humans; D015994:Incidence; D007431:Intraoperative Complications / Q000453:epidemiology* / Q000209:etiology; D008297:Male; D009339:Needles; D016602:Needlestick Injuries / Q000453:epidemiology* / Q000209:etiology; D009407:Nerve Block / Q000295:instrumentation / Q000379:methods*; D010292:Paresthesia / Q000209:etiology; D018084:Ultrasonography, Interventional
keywords: Bloqueo del nervio femoral; Femoral nerve blockade; Guiado por ecografía; Nerve puncture; Punción nerviosa; Ultrasound-guided