Ultrasound-Guided Femoral Nerve Blocks

Ultrasound-Guided Regional Anesthesia of the Femoral Nerve in the Pediatric Emergency Department

OBJECTIVES

Femur fractures are painful, and use of systemic opioids and other sedatives can be dangerous in pediatric patients. The fascia iliaca compartment nerve block and femoral nerve block are regional anesthesia techniques to provide analgesia by anesthetizing the femoral nerve. They are widely used in adult patients and are associated with good effect and reduced opioid use. Ultrasound (US) guidance of nerve blocks can increase their safety and efficacy. We sought to report on the use and safety of US-guided regional anesthesia of the femoral nerve performed by emergency physicians for femur fractures in 6 pediatric emergency departments.

METHODS

Records were queried at 6 pediatric EDs across North America to identify patients with femur fractures managed with US-guided regional anesthesia of the femoral nerve between January 1, 2016, and May 1, 2021. Data were abstracted regarding demographics, injury pattern, nerve block technique, and analgesic use before and after nerve block.

RESULTS

Eighty-five cases were identified. Median age was 5 years (interquartile range, 2-9 years). Most patients were male and had sustained blunt trauma (59% low-mechanism falls). Ninety-four percent of injuries were managed operatively. Most patients (79%) received intravenous opioid analgesia before their nerve block. Ropivacaine was the most common local anesthetic used (69% of blocks). No procedural complications or adverse effects were identified.

CONCLUSIONS

Ultrasound-guided regional anesthesia of the femoral nerve is widely performed and can be performed safely on pediatric patients by emergency physicians and trainees in the pediatric emergency department.

Prehospital Ultrasound-Guided Pediatric Fascia Iliaca Block

The fascia iliaca block (FIB) provides effective regional anesthesia for fractures of the femur. There is 1 previous case report of a prehospital FIB in a child using a landmark technique. We report the successful prehospital application of a FIB using ultrasound guidance in a 7-year-old girl.

Analysis of the Effect of Applying Ultrasound-Guided Nerve Block Anesthesia to Fracture Patients in the Context of Internet-Based Blockchain

In the process of surgical treatment, the introduction of ultrasound technology to implement nerve block anesthesia can make the operations of patients with fractures under visualization and it can also significantly improve the anesthesia effect. With this technology, it is possible to minimize the anesthesia operation causing accidental injury and lay a good foundation for the smooth operation of surgical treatment. Blockchain technology is a new decentralized infrastructure and distributed computing paradigm. This technology has great development opportunities in the medical field and is expected to play an important role in the construction of Internet medical ecology. This study aims to investigate the effect of ultrasound-guided nerve block anesthesia on fracture treatment in the context of blockchain. This method has high application value and potential in medical data sharing, reducing treatment costs, improving the medical claims system, strengthening medical management, and optimizing medical decision-making using blockchain technology. This study also addresses the uniqueness and complexity of ultrasound-guided nerve block anesthesia itself and analyzes the effect of the proposed method. The analysis shows that using the internet-based blockchain ultrasound-guided subacromial nerve block anesthesia for fracture patients is effective, and the patient's vital signs are stable, and the block is effective.

Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know

Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.

Newer nerve blocks in pediatric surgery

PURPOSE OF THE REVIEW

The purpose of this manuscript is to provide a brief discussion of the current direction in pediatric regional anesthesia, highlighting both newer nerve blocks and techniques and traditional nerve blocks.

RECENT FINDINGS

The number of nerve blocks performed in pediatric patients continues to increase. This growth is likely related in part to the recent focus on perioperative multimodal analgesia, in addition to growing data demonstrating safety and efficacy in this patient population. Multiple studies by the Pediatric Regional Anesthesia Network (PRAN) and the French-Language Society of Pediatric Anesthesiologists (ADARPEF) have demonstrated lack of major complications and general overall safety with pediatric nerve blocks. The growing prevalence of ultrasound-guided regional anesthesia has not only improved the safety profile, but also increased the efficacy of both peripheral nerve blocks and perineural catheters.

SUMMARY

As the push for multimodal analgesia increases and the breadth of pediatric regional anesthesia continues to expand, further large prospective studies will be needed to demonstrate continued efficacy and overall safety.

Ultrasound-Guided Popliteal Sciatic Nerve Block for an Ankle Laceration in a Pediatric Emergency Department

Although ultrasound-guided peripheral nerve block has recently been introduced into pediatric emergency departments, knowledge of its use is limited. We present here a case demonstrating the safety and effectiveness of ultrasound-guided popliteal sciatic nerve block for a pediatric spoke injury in a pediatric emergency department setting.

Drug-Induced Pseudoallergy: A Review of the Causes and Mechanisms

Adverse drug reactions occur frequently and can trigger pseudoallergy, which has become a serious threat to public health. Pseudoallergy is a typical non-immune anaphylactic reaction characterized by the independence of antigen-specific immune responses. In the clinic, pseudoallergy is often elicited by the first dose of medication, and here lies its unpredictability and occasional lethal outcome. However, the mechanisms of pseudoallergy are not well understood. This review focusses on the causes and mechanisms of pseudoallergy induced by drugs. Two categories of mechanisms will be considered, namely, (1) complement activation-related pseudoallergy and (2) mast cell activation-related pseudoallergy. The factors that induce pseudoallergy include opioid drugs, complement activation-related pseudoallergenic drugs, nonsteroidal anti-inflammatory drugs and traditional Chinese medicine injections.

A prospective, double-blinded, randomized comparison of ultrasound-guided femoral nerve block with lateral femoral cutaneous nerve block versus standard anesthetic management for pain control during and after traumatic femur fracture repair in the pediatric population

Background

Traumatic injury of the femur resulting in femoral fracture may result in significant postoperative pain. As with other causes of acute pain, regional anesthesia may offer a benefit over conventional therapy with intravenous opioids. This study prospectively assesses the effects of femoral nerve blockade with a lateral femoral cutaneous nerve block (FN-LFCN) on intraoperative anesthetic requirements, postoperative pain scores, and opioid requirements.

Materials and methods

Seventeen pediatric patients (age 2–18 years) undergoing surgical repair of a traumatic femur fracture fulfilled the study criteria and were randomly assigned to general anesthesia with either an FN-LFCN block (n = 10) or intravenous opioids (n = 7). All patients received a general anesthetic with isoflurane for maintenance anesthesia during the surgical repair of the femur fracture. Patients randomized to the FN-LFCN block group received ultrasound-guided nerve blockade using ropivacaine (0.2%/0.5% based on patient weight). At the conclusion of surgery, the airway device was removed once tracheal extubation criteria were achieved, and patients were transported to the post-anesthesia care unit (PACU) for recovery and assessment of pain by a blinded study nurse.

Results

The final study cohort included 17 patients (n = 10 for FN-LFCN block group; n = 7 for the intravenous opioid group). Although the median of the maximum postoperative pain scores in the regional group was 0, this did not reach statistical significance when compared to the median pain score of 3 in the intravenous opioid group. Likewise, no difference between the two groups was noted when comparing intraoperative anesthetic requirements, opioid requirements (intraoperative, in the post-anesthesia recovery room, and in the inpatient ward), and the time to first opioid requirement postoperatively in the inpatient ward.

Conclusion

This prospective, randomized, double-blinded study failed to demonstrate a clear benefit of regional anesthesia over intravenous opioids intraoperatively and postoperatively during repair of femoral shaft fractures in the pediatric population.

Ultrasound-Guided Femoral Nerve Blockage in A Patellar Dislocation: An Effective Technique for Emergency Physicians

BACKGROUND

Patellar dislocation is an orthopedic emergency and its reduction can be painful. The aim of this case is to show that the ultrasound-guided femoral nerve blockage can be effectively used in the pain management of patellar reduction in the emergency department (ED).

CASE REPORT

A 21-year-old man was admitted to our ED after suffering a fall down a flight of stairs. The initial physical examination and plain radiography showed a patellar dislocation in the right knee. We performed an ultrasound-guided femoral nerve blockage to provide a pain-free and comfortable patellar reduction. To our best knowledge, there is no manuscript except an old case series about use of the ultrasound-guided femoral nerve blockage in the management of patellar reduction in the medical literature. Procedural sedation is the preferred method used for this purpose in ED, but these medications need to be closely monitored because of their potential complications, such as nausea, vomiting, allergic reactions, and respiratory depression. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ultrasound-guided femoral nerve blockage gave rapid and effective pain control without any complication during the reduction in this patient. Therefore, we suggest this technique be used for pain management during the reduction of a dislocated patella in the ED.

Management of acute pediatric pain in the emergency department

PURPOSE OF REVIEW

This article provides a summary of recommendations for the multimodal and multidisciplinary approach to acute pediatric pain management and highlights recent research on this topic.

RECENT FINDINGS

Recent literature has focused on updating recommendations for the use of various analgesics in the pediatric population. While codeine is no longer recommended due to increasing evidence of adverse effects, the more liberal use of intranasal fentanyl is now encouraged because of the ease of administration and rapid delivery. The evidence base for the use of ultrasound-guided regional nerve blocks by qualified providers in the acute pediatric pain setting continues to grow.

SUMMARY

The pediatric emergency medicine provider should be able to assess pain and develop individualized pain plans by utilizing a range of nonpharmacologic and pharmacologic strategies. Knowledge of the most recent literature and changes in recommendations for various pain medications is essential.