Can ultrasound-guided infraclavicular block be an alternative option for forearm reduction in the emergency department? A prospective randomized study

Peripheral nerve blocks for closed reduction of distal radius fractures-A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Peripheral nerve blocks may provide better conditions for closed reduction of distal radius fractures as compared to other more frequently used modalities. In this systematic review, we evaluate existing evidence on the effect and harm of peripheral nerve blocks for closed reduction of distal radius fractures in adults.

METHODS

We performed a systematic review with meta-analysis and trial sequential analysis including trials investigating the use of peripheral nerve blocks for closed reduction of distal radius fractures. Co-primary outcomes were (1) the quality of the closed reduction measured as the proportion of participants needing surgery afterwards and (2) pain during closed reduction.

RESULTS

Six trials (n = 312) met the inclusion criteria. One trial reported on the need for surgery with 4 of 25 participants receiving nerve block compared to 7 of 25 receiving haematoma block needing surgery (RR 0.57, 96.7% CI [0.19; 1.71], p = .50). Four trials reported pain during closed reduction. In a meta-analysis, pain was not statistically significantly reduced with a nerve block (-2.1 Numeric Rating Scale (NRS) points (0-10), 96.7% CI [-4.4; 0.2], p = .07, tau2 = 5.4, I2 = 97%, TSA-adj. 95% CI [-11.5; 7.3]). No trial sequential boundaries were crossed, and the required information size was not met. Pre-planned subgroup analysis on trials evaluating ultrasound guided peripheral nerve blocks (patients = 110) showed a significant decrease in 'pain during reduction' (-4.1 NRS, 96.7% CI [-5.5; -2.6], p < .01, tau2 = 0.9, I2 = 80%). All trial results were at high risk of bias and the certainty of the evidence was very low.

CONCLUSION

The certainty of evidence on the effect of peripheral nerve blocks for closed reduction of distal radius fractures is currently very low. Peripheral nerve blocks performed with ultrasound guidance may potentially reduce pain during closed reduction. High-quality clinical trials are warranted.

Ultrasound-guided nerve blocks in emergency medicine practice: 2022 updates

OBJECTIVES

In the Emergency Department (ED), ultrasound-guided nerve blocks (UGNBs) have become a cornerstone of multimodal pain regimens. We investigated current national practices of UGNBs across academic medical center EDs, and how these trends have changed over time.

METHODS

We conducted a cross-sectional electronic survey of academic EDs with ultrasound fellowships across the United States. Twenty-item questionnaires exploring UGNB practice patterns, training, and complications were distributed between November 2021-June 2022. Data was manually curated, and descriptive statistics were performed. The survey results were then compared to results from Amini et al. 2016 UGNB survey to identify trends.

RESULTS

The response rate was 80.5% (87 of 108 programs). One hundred percent of responding programs perform UGNB at their institutions, with 29% (95% confidence interval (CI), 20%-39%) performing at least 5 blocks monthly. Forearm UGNB are most commonly performed (96% of programs (95% CI, 93%-100%)). Pain control for fractures is the most common indication (84%; 95% CI, 76%-91%). Eighty-five percent (95% CI, 77%-92%) of programs report at least 80% of UGNB performed are effective. Eighty-five percent (95% CI, 66%-85%) of programs have had no reported complications from UGNB performed by emergency providers at their institution. The remaining 15% (95% CI, 8%-23%) report an average of 1 complication annually.

CONCLUSIONS

All programs participating in our study report performing UGNB in their ED, which is a 16% increase over the last 5 years. UGNB's are currently performed safely and effectively in the ED, however practice improvements can still be made. Creating multi-disciplinary committees at local and national levels can standardize guidelines and practice policies to optimize patient safety and outcomes.

Regional Anesthesia for Acute Pain Treatment in Pre-Hospital and In-Hospital Emergency Medicine

BACKGROUND

More than half of all emergency department patients seek help for acute pain, which is usually of musculoskeletal origin. Acute pain is often inadequately treated even today, particularly in children and in older patients. In this study, we assess the potential role of regional anesthetic methods in improving the treatment of pain in the preclinical and clinical emergency setting.

METHODS

Pain-related reasons for admission were identified and quantified from emergency admission data. A structured literature search was carried out for clinical studies on the treatment of pain in the emergency setting, and a before-and-after comparison of the pain relief achieved with established vs. newer regional anesthetic methods was performed.

RESULTS

43% of emergency patients presented with acute musculoskeletal pain. The literature search yielded 3732 hits for screening; data on entity-specific pain therapy spectra were extracted from 153 studies and presented for the main pain regions. The degree of pain relief obtained through regional anesthetic procedures, on a nominal rating scale from 0 to 10, was 4 to 7 points for acute back and chest wall pain, >6 for shoulder pain, 5 to 7 for hand and forearm injuries, and >4 for hip fractures. These results were as good as, or better than, those obtained by analgesia/sedation with strong opioids.

CONCLUSION

Modern regional anesthetic techniques can improve acute pain management in the emergency department and, to some extent, in the pre-hospital setting as well. Pain relief with these techniques is quantifiably better than with strong opioids in some clinical situations; moreover, there is evidence of further advantages including process optimization and fewer complications. Data for comparative study remain scarce because of a lack of standardization.

Ultrasound-Guided Peripheral Nerve Blocks: A Practical Review for Acute Cancer-Related Pain

PURPOSE OF REVIEW

Ultrasound-guided regional techniques, including catheter-based approaches, are a subset of interventional therapies that have gained interest as an option for managing acute cancer-related pain. The authors sought to review the available published evidence and to discuss practical recommendations for expanding access to such therapies.

RECENT FINDINGS

In a MEDLINE/Pubmed search of ultrasound-guided peripheral nerve blocks and peripheral nerve catheters for specific anatomic targets, a total of 28 case reports and case series were identified. Included studies described improved analgesia and reduced opioid requirements with highly variable duration of effect. Current level of evidence remains limited. Pain is a symptom that markedly impacts the quality of life of cancer patients and ultrasound-guided regional techniques are a promising therapeutic option albeit with a limited evidence base. Practical recommendations offered for coordinating access to such therapies in the inpatient, emergency department, and outpatient settings may expand interest and facilitate higher quality research.

Impact of Insurance Benefits and Education on Point-of-Care Ultrasound Use in a Single Emergency Department: An Interrupted Time Series Analysis

Background and Objectives: Point-of-care ultrasound (POCUS) is a useful tool that helps clinicians properly treat patients in emergency department (ED). This study aimed to evaluate the impact of specific interventions on the use of POCUS in the ED. Materials and Methods: This retrospective study used an interrupted time series analysis to assess how interventions changed the use of POCUS in the emergency department of a tertiary medical institute in South Korea from October 2016 to February 2021. We chose two main interventions—expansion of benefit coverage of the National Health Insurance (NHI) for emergency ultrasound (EUS) and annual ultrasound educational workshops. The primary variable was the EUS rate, defined as the number of EUS scans per 1000 eligible patients per month. We compared the level and slope of EUS rates before and after interventions. Results: A total of 5188 scanned records were included. Before interventions, the EUS rate had increased gradually. After interventions, except for the first workshop, the EUS rate immediately increased significantly (p < 0.05). The difference in the EUS rate according to the expansion of the NHI was estimated to be the largest (p < 0.001). However, the change in slope significantly decreased after the third workshop during the coronavirus disease 2019 pandemic (p = 0.004). The EUS rate increased significantly in the presence of physicians participating in intensive POCUS training (p < 0.001). Conclusion: This study found that expansion of insurance coverage for EUS and ultrasound education led to a significant and immediate increase in the use of POCUS, suggesting that POCUS use can be increased by improving education and insurance benefits.