Pick-Up-and-Go Block Bags for Fascia Ilaca Blocks

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Ultrasound-guided regional anesthesia is a mainstay of multimodal pain control and is becoming an increasingly important part of emergency medical care. Regional anesthesia allows for maximal analgesia while minimizing the adverse effects of opioids, such as respiratory depression and sedation. The fascia iliaca block is one such procedure that provides regional anesthesia in the Emergency Department (ED) for proximal femur fractures and hip fractures.1 This plane block is performed by depositing a moderate volume of local anesthetic, usually bupivacaine, into the potential space between the fascia iliaca and the iliopsoas muscle. The procedure provides analgesia in the distribution of the femoral nerve, as well as the obturator nerve and lateral femoral cutaneous nerve. 1 Patients who receive this procedure experience improved pain scores and a reduction in the need for opioid medication.2–5 The use of preoperative regional nerve blocks, specifically including older patients with hip fractures, is supported by 2022 American Association of Orthopedic Surgeon guidelines.5,6

At Rutgers New Jersey Medical School, we developed a teaching paradigm for the fascia iliaca block, with an online didactic session followed by a hands-on simulated skills session offered to faculty and residents (Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model).

Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model.
Figure 1A
Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model.
Figure 1B

Later in the year, we performed a quality assurance project in order to determine what barriers existed to performing this block, in order to maximize the number of eligible patients that received this valuable procedure. We found that the fascia iliaca block was performed about 16% of the time when indicated (Figure 2).

A bar graph indicating that, of those who received a nerve block, 87 were for hip/femur fractures (~3-4 per week), 16% (95CI: 10% to 25%) received the block, and 90% (95CI: 82% to 95%) completed the survey.
Figure 2. Percentage of eligible patients who received the block.

The most common reason for the block not being performed was the perceived lack of time during a busy clinical shift (Figure 3), which was a factor that was present in more than ¾ of missed opportunities.7 We theorized that this limitation came from a combination of the time required to obtain consent from the patient, gather supplies, coordinate with the admitting Orthopedics service, and ultimately perform the procedure.

A bar graph indicating the number and strength of each agreement for each response.
Figure 3. Reasons that the block was not performed.

To address this barrier, we created ready-made pick-up-and-go nerve block kits containing all the necessary materials for performing ultrasound-guided nerve blocks in the ED (Figure 4). These kits include sterile gloves, ultrasound probe covers, sterile drapes, spinal needles, syringes, IV tubing, nerve block reference materials, and a consent form. We placed the kits in a centralized location in the ED for ease of access.

Figure 4A. A collection of nerve block kits ready for use.
Figure 4B. Contents of a nerve block kit.

As a result of this intervention, we have anecdotally noted an increased number of procedures performed, with a complete analysis forthcoming. As our program increases the scope and scale of regional anesthesia procedures offered to patients, the nerve block kits will hopefully eliminate a barrier to performing nerve blocks and thus facilitate the deliverance of high-quality patient-centered analgesia to the largest number of patients possible.

References

  1. Chesters A, Atkinson P. Fascia iliaca block for pain relief from proximal femoral fracture in the emergency department: a review of the literature. Emerg Med J 2014; 31(e1):e84–e87. doi:10.1136/emermed-2013-203073.
  2. Groot L, Dijksman LM, Simons MP, Zwartsenburg MM, Rebel JR. Single fascia iliaca compartment block is safe and effective for emergency pain relief in hip-fracture patients. West J Emerg Med 2015; 16:1188–1193. doi:10.5811/westjem.2015.10.28270.
  3. Ritcey B, Pageau P, Woo MY, Perry JJ. Regional nerve blocks for hip and femoral neck fractures in the emergency department: A systematic review. CJEM 2016; 18:37–47. doi:10.1017/cem.2015.75.
  4. Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J Emerg Med 2012; 43:692–697. doi:10.1016/j.jemermed.2012.01.050.
  5. Kolodychuk N, Krebs JC, Stenberg R, Talmage L, Meehan A, DiNicola N. Fascia iliaca blocks performed in the emergency department decrease opioid consumption and length of stay in patients with hip fracture. J Orthop Trauma 2022; 36:142–146. doi:10.1097/BOT.0000000000002220.
  6. O’Connor M, Switzer J. AAOS Clinical practice guideline summary: Management of hip fractures in older adults. J Am Acad Orthop Surg 2022; 30(20):e1291–e1296. doi: 10.5435/JAAOS-D-22-00125.
  7. Alsharif P, Muckey E, Lu H, et al. Emergency department workflow limits the utilization of fascia iliaca blocks for hip and femur fractures. Academic Emergency Medicine 2022; 29(S1). https://doi.org/10.1111/acem.14511.

Peter Alsharif MD, Marwa Ali MD, Helen Lu MD, Robert James Adrian MD, Annette Mueller MD MBA, Ilya Ostrovsky MD, and Stephen Alerhand MD, are from the Department of Emergency Medicine at Rutgers New Jersey Medical School in Newark, New York.