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    Safety standards vs. practicality/reality of RA in different settings American perspective: From USRA to POCUS – an easy transition for the regional anaesthetist

    Melody HERMAN
    22/12/2024

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    Australian Perspective: Acute pain service with pain nurse practitioner performing blocks.

    With increasing elderly population globally, rib and hip fractures have become commonplace.

    Unfortunately, fractured neck of femur (NOF) has 1 year mortality rate as high as 18-25%1-4. Surgery within 36 hours, involvement of an orthogeriatric team and regional anaesthesia techniques for pain management are interventions that can improve outcomes5-7.

    In most Australian hospitals and globally, patients with fractured NOF receive a single shot femoral or fascia iliaca compartment block (FICB) on arrival in the Emergency Department (ED)8-10. Systemic opioids then become the mainstay of analgesia which is often poorly tolerated by this frail, elderly cohort.

    Consultant anaesthetists’ unavailability to perform ultrasound guided regional anaesthesia (USGRA) outside theatre, hinders access to these much-needed blocks. Hence, most blocks are performed as a rescue analgesic technique when all else fails! Recognising this gap in the pain management, our pain nurse practitioner underwent rigorous training and assessment to upskill herself in specific USGRA techniques.

    Currently, at our institution, the acute pain service (APS) offers daily ward based US guided FICB to all our fractured NOF patients awaiting surgery. Similarly, high risk rib fracture patients receive erector spinae catheter as the main analgesic technique in combination with multimodal analgesia. Timely access to blocks led by nurse practitioner has not only resulted in exceptional pain management but also a steep increase in number of regional anaesthesia techniques at our institution which has created opportunities for anaesthesia trainees to get more hands-on experience.

    Results from a retrospective study conducted at our institution focusing on outcomes in these patients, safety of these blocks and a nursing staff survey on effect of these blocks on pressure care, pain management and their overall workload will be discussed.

     

    References:

     

    1.     Australian Institute of Health and Welfare (2023) Hip Fracture care pathways in Australia, Catalogue number PHE 336, AIHW, Australian Government.

    2.     Dimet-Wiley A, Golovko G, Watowich S. One-Year Postfracture Mortality Rate in Older Adults With Hip Fractures Relative to Other Lower Extremity Fractures: Retrospective Cohort Study JMIR Aging 2022;5(1): e32683 URL:https://aging.jmir.org/2022/1/e32683

    DOI: 10.2196/32683

    3.     Mundi S, Pindiprolu B, Simunovic N, Bhandari M. Similar mortality rates in hip fracture patients over the past 31 years: a systematic review of RCTs. Acta Orthopaedica. 2014;85(1):54-9. doi:10.3109/17453674.2013.878831

    4.     Leung MTY, Marquina C, Turner JP, Ilomaki J, Tran T, Bell JS. Hip fracture incidence and post-fracture mortality in Victoria, Australia: a state-wide cohort study. Arch Osteoporos. 2023 Apr 29;18(1):56. doi: 10.1007/s11657-023-01254-6. Erratum in: Arch Osteoporos. 2023 May 22;18(1):74. doi: 10.1007/s11657-023-01286-y. PMID: 37119328; PMCID: PMC10148778

    5.     https://www.nice.org.uk/guidance/cg124

    6.     Griffiths R, Babu S, Dixon P, Freeman N, Hurford D, Kelleher E, Moppett I, Ray D, Sahota O, Shields M and White S. (2021), Guideline for the management of hip fractures 2020. Anaesthesia, 76: 225-237.

    https://doi.org/10.1111/anae.15291

    7.     Pissens S, Cavens L, Joshi G.P, Bonnet M.P, Sauter A, Raeder J, Van de Velde M, on behalf of the PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy (esrA), Pain management after hip fracture repair surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Acta Anaesth.Bel. 2024;75(1):15-31 https://doi.org/10.56126/75.1.04

    8.     Australian and New Zealand Hip Fracture Registry Annual Report 2023. https://anzhfr.org/wp-content/uploads/sites/1164/2023/09/ANZHFR-2023-Annual-Report-%E2%80%93-eReport-%E2%80%93-FINAL.pdf

    9.     Steenberg J, Moller A. M. Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation. British Journal of Anaesthesia, 2018;120(6):1368-1380

    https://doi.org/10.1016/j.bja.2017.12.042

    10.  O’Reilly N, Desmet M, Kearns R. Fascia iliaca compartment block. BJA Education 2019;19(6):191-197

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