ASRA Pain Medicine Update

Improved patient outcome benefits related to the provision of regional anesthesia in the perioperative setting have been well documented, including superior analgesia and reduced systemic analgesic use, hospital length of stay, and cardiopulmonary complications.^{1},{2} As a result, regional anesthesia techniques are becoming more common and novel blocks and approaches are being regularly described. Mounting literature suggests the benefits of such techniques can improve patient care in a variety of scenarios outside of the operating room, most notably in acute care settings such as emergency medicine and critical care.^{3},{4} To improve patient access to the techniques while optimizing efficacy and safety, regional anesthesia specialists should help train non-anesthesia physicians to perform peripheral nerve blocks.

This provides an extraordinary opportunity for regional anesthesia specialists to share their knowledge and expertise with other specialists in order to improve access and provide ongoing quality patient care.

Trauma patients in the emergency department, especially those with hip fractures, represent the most studied population receiving peripheral nerve blocks outside of the operating room. Many are older than 65 years with multiple comorbidities and likely recognize the greatest benefit from early institution of a peripheral nerve block. They are frequently undertreated for pain because of concerns about hemodynamic instability, respiratory depression, and delirium, yet poorly managed pain can lead to similar consequences.^{5},{6}

The fascia iliaca compartment block, femoral nerve block, and three-in-one femoral nerve block have all been studied for hip fracture pain in the emergency department.^{7},{8},{9}Results from a systematic review by Ritcey et al. showed that patients with hip fractures who were treated in the emergency department with one of those peripheral nerve blocks reported equal or superior benefit in pain relief when compared to those receiving standard systemic analgesics. In addition, patients receiving a block required significantly fewer systemic opioids without experiencing an increase in complications related to the peripheral nerve block.^{10} Another systematic review by Abou-Setta et al. showed that hip fracture patients receiving nerve blockade pre- or intraoperatively had a significantly reduced risk of developing delirium.¹¹

Peripheral nerve blocks for trauma beyond the operative setting are already included in national and local management guidelines in North America and Europe.^{{12}, {13}, {14}} The American Academy of Orthopedic Surgeons strongly supports the use of regional anesthesia to improve preoperative pain control in hip fracture management.¹² National Institute for Health and Care Excellence (NICE) guidelines in the United Kingdom and provincial guidelines in Canada for hip fracture management both include peripheral nerve blockade in multimodal analgesia strategies.^{13},{14}

With approximately 500,000 hip fractures occurring annually in the United States alone that may benefit from the early provision of a nerve block, practitioners involved with patients’ initial management should be trained in safe and effective administration of those blocks. Unfortunately, many emergency medicine program lack experience and credentialing pathways for regional anesthesia.^{15} Anesthesiologists trained in regional anesthesia may not be available at all hours to provide such procedures on patient presentation. This provides an extraordinary opportunity for regional anesthesia specialists to share their knowledge and expertise with other specialists in order to improve access and provide ongoing quality patient care.

The key to success is to have clear training and credential pathways, perhaps for selective nerve blocks, before nonanesthesiologists start performing regional anesthesia on patients. Proper training takes time and effort from both teachers and learners because it involves not only performing the nerve block itself, but rather the whole package of dose selection, complications and their management, and patient selection. Who better than anesthesiologists who specialize in regional anesthesia to teach about something they are passionate about and good at? The programs should also be evaluated to ensure effectiveness of the training, as well as quality and safety of care delivered.

Because of the obvious benefit to patient care and the already increasing use of peripheral nerve blocks outside of the operating room, anesthesiologists must help train other specialists rather than nonanesthesiologists finding their own way to acquire the skills. Only through advocacy for patient quality and collaboration can anesthesiologists continue to be recognized as experts beyond the operating room.

“Knowledge alone is not power. The sharing of our knowledge is when knowledge becomes powerful.”

-Rich Simmonds

References

1. Kettner SC, Willschke H, Marhofer P. Does regional anesthesia really improve outcome? Br J Anaesthesia. 2011;107(Suppl 1):i90–i95. https://doi.org/10.1093/bja/aer340
2. Ahmed J, Lim M, Khan S, et al. Predictors of length of stay in patients having elective colorectal surgery within an enhanced recovery protocol. Int J Surg. 2010;8:628–632. https://doi.org/10.1016/j.ijsu.2010.07.294
3. Kessler J, Marhofer P, Hopkins PM, Hollmann MW. Peripheral regional anesthesia and outcome: lessons learned from the last 10 years. Br J Anaesth. 2015;114:728–745. https://doi.org/10.1093/bja/aeu559
4. De Buck F, Devroe S, Missant C, Van de Velde M. Regional anesthesia outside the operating room: indications and techniques. Curr Opin Anaesthesiol. 2012;25:501–507. https://doi.org/10.1097/ACO.0b013e3283556f58
5. Holdgate A, Shepherd SA, Huckson S. Patterns of analgesia for fractured neck of femur in Australian emergency departments. Emerg Med Australas. 2010;22:3–8. https://doi.org/10.1111/j.1742-6723.2009.01246.x
6. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003;58:76–81.
7. Madabushi R, Rajappa G, Thammanna P, Iyer S. Fascia iliaca block vs intravenous fentanyl as an analgesic technique before positioning for spinal anesthesia in patients undergoing surgery for femur fractures—a randomized trial. J Clin Anesth. 2016;35:398–403. https://doi.org/10.1016/j.jclinane.2016.09.014
8. Mittal R, Vermani E. Femoral nerve blocks in fractures of femur: variation in the current UK practice and a review of the literature. Emerg Med J. 2014;31:143–147. https://doi.org/10.1136/emermed-2012-201546
9. Beaudoin FL, Haran JP, Liebmann O. A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Acad Emerg Med. 2013;20:584–591. https://doi.org/10.1111/acem.12154
10. Ritcey B, Pageau P, Woo M, Perry J. Regional nerve blocks for hip and femoral neck fractures in the emergency department: a systematic review. 2016;18:37–47. https://doi.org/10.1017/cem.2015.75
11. Abou-Setta A, Beaupre LA, Rashiq S, et al. Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Ann Intern Med. 2011;155:234–245. https://doi.org/10.7326/0003-4819-155-4-201108160-00346
12. American Academy of Orthopedic Surgeons. Management of hip fractures in the elderly: evidence-based clinical practice guideline. Rosemont, IL: AAOS; 2014. https://www.aaos.org/research/guidelines/HipFxGuideline_rev.pdf. Accessed August 6, 2018.
13. National Clinical Guideline Center. The management of hip fracture in adults. London, UK: Royal College of Physicians; 2011. https://www.nice.org.uk/guidance/cg124/evidence/full-guideline-pdf-183081997. Accessed August 10, 2018.
14. Health Quality Ontario. Hip fracture: care for people with fragility fractures 2017. Toronto, Ontario, Canada: Health Quality Ontario; 2017. http://www.hqontario.ca/portals/0/documents/evidence/quality-standards/qs-hip-fracture-clinical-guide-en.pdf. Accessed August 8, 2018.
15. Amini R, Kartchner JZ, Nagdev A, Adhikari S. Ultrasound-guided nerve blocks in emergency medicine practice. J Ultrasound Med. 2016;35:731–736. https://doi.org/10.7863/ultra.15.05095