A Robust Approach to Implementing Fascia Iliaca Compartment Nerve Blocks in Hip Fracture Patients

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1.5 ANCC Contact Hours A Robust Approach to Implementing Fascia Iliaca Compartment Nerve Blocks in Hip Fracture Patients

Mark G. Williams ▼ Zachary Jeffery ▼ Henry W. Corner ▼ John Charity ▼ Marina Quantick ▼ Natalie Sartin

BACKGROUND: A clear imperative exists to optimize the (Ettinger, Black, Dawson-Hughes, Pressman, & Melton, preoperative pain management of hip fracture patients. 2010). However, the US age-adjusted incidence in those Increasingly, fascia iliaca compartment blocks (FICBs) are be- older than 65 years was 793.5 per 100,000 for women ing effectively utilized as an adjunct to oral analgesia in the and 369.0 per 100,000 for men. Although age-adjusted emergency department. mortality and hip fracture incidence declined in the PURPOSE: We investigated the feasibility, safety, and United States from 1995 to 2005, patients are more likely to have comorbidities such as congestive heart failure, delivery rate when junior doctors and specialist nurses are chronic pulmonary disease, and diabetes (Brauer, Coca- trained in FICBs delivery, alongside the introduction of a Perraillon, Cutler, & Rosen, 2009). Patients with more step-by-step proforma. comorbidities have higher rates of postoperative compli- METHODS: We conducted a retrospective study of hip cations associated with an increased healthcare burden fractures patients presenting preinterventions (n = 138) (Menzies, Mendelson, Kates, & Friedman, 2012). Prior between October and December 2014 and postinterven- to surgical ﬁ xation, hip fracture patients often experi- tions ( n = 246) between April and August 2015. Outcomes ence high levels of pain and distress. Achieving effective analyzed included delivery frequency, anesthetic dosages analgesia preoperatively while avoiding adverse effects used, and procedure documentation. of drugs can be challenging, particularly in this increas- RESULTS: Preintervention, FICB was performed in 40% ingly frail and comorbid population. ( n = 51) of eligible patients, with an improvement to 72% A fascia iliaca compartment block (FICB) is an es- tablished regional anesthetic technique that can be ( n = 160) postintervention. Postinterventions, 98% of FICBs reliably performed using anatomical landmarks, re- were performed with the anesthetic dose recommended—a sulting in a block of the femoral, lateral cutaneous, prescription between 75 and 100 mg of 0.25% levobupiv- and obturator nerves. The FICB utilizes a high-vol- acaine. No adverse patient outcomes, relating to the inter- ume, low-concentration bolus to provide cutaneous ventions implemented, were noted during the study period. anesthesia for up to 10 hours. The delivery approach CONCLUSION: Delivery of FICB by junior doctors and spe- avoids the femoral artery and the vein (see Figure 1 ), cialist nurses in the emergency department is feasible, safe, hence its suitability for acutely diagnosed hip frac- and improves the proportion of patients receiving blocks. tures in the emergency department (ED). It provides

Mark G. Williams, MBChB, MRCS, Junior Doctor, Royal Devon and Introduction Exeter Hospital, England. As a result of an aging population, according to epide- Zachary Jeffery, BMBS, Junior Doctor, Royal Devon and Exeter Hospital, miologic projections, the global annual number of hip England. fractures will rise to 6.26 million by the year 2050 Henry W. Corner, Bm, BMedSci, Junior Doctor, Royal Devon and Exeter (Kannus et al., 1996). Currently, an estimated 65,000 hip Hospital, England. fractures occur annually in the United Kingdom, with John Charity, MD, MRCS, ChM T&O (Ed), Associate Specialist in Trauma the incidence reported as 349 per 100,000 for females and Orthopaedics Department, Royal Devon and Exeter Hospital, and 140 per 100,000 for males ( Kanis, Odén, & England. McCloskey, 2012). Hip fracture patients have an average Marina Quantick, Specialist Pain Nurse, Department of Anesthesia, 8% mortality at 30 days and up to 30% mortality at 1 Royal Devon and Exeter Hospital, England. year (British Orthopaedic Association, 2012). In com- Natalie Sartin, BMBS, Junior Doctor, Royal Devon and Exeter Hospital, parison, an estimated 340,000 hip fractures occur annu- England. ally in the United Sates, with an incidence of 260 per The authors declare no conﬂ icts of interest or sources of funding. 100,000 for females and 122 per 100,000 for males DOI: 10.1097/NOR.0000000000000449

© 2018 by National Association of Orthopaedic Nurses Orthopaedic Nursing • May/June 2018 • Volume 37 • Number 3 185 Copyright © 2018 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. with hip fractures, between October and December 2014. Interventions aiming to improve practice were implemented including training of personnel on the technique, updating guidelines, and ensuring that guidelines were easily accessible to clinicians. Junior doctors of all levels (n = 10) consulting in the ED, emergency nurse practitioners (ENPs; n = 3), and anesthetic nurse practitioners ( n = 3) received group or individual tutorials in performing FICB. Prior to the study, junior doctors and ENPs were not delivering FICB, and no formalized training in FICB delivery had been provided for this group. Following training, individuals delivering FICB were directly supervised until they were deemed competent (typically fewer than three procedures). As a quality aid, a concise proforma was introduced with preprocedure, procedure, and postprocedure sec- tions. This serves as an aide-memoire to the landmark technique, ensuring clear documentation of the procedure and absence of contraindications, as shown in Figure 2. A new guideline was introduced that promotes FICB F IGURE 1. Diagram demonstrating the anatomy and needle delivery in the ED during the fi rst 4 hours from arrival entry point used for fascia iliaca compartment block delivery for all patients with acute, radiologically diagnosed hip (axial plane). Image from Tomar, G.S., et al (2011). Fascia iliaca fractures. We utilized the evidence presented in the compartmental block with and without clonidine. Journal of American Academy of Orthopaedic Surgeons (AAOS) Anesthesia and Clinical Research, 2, 121. DOI: 10.4172/2155- clinical guideline regarding preoperative regional anes- 6148.1000121. Open Access journal. thesia. We advocate the use of levobupivacaine—30 mL for patients weighing between 40 and 60 kg and 40 mL effective pain relief, costs little, is minimally invasive, for those more than 60 kg (based on an estimated and can have an opioid sparing effect ( Elkhodair, weight). Postdelivery, monitoring for signs of local anes- Mortazavi, Chester, & Pereira, 2011 ; Godoy Monzon, thetic toxicity (such as tinnitus, blurred vision, drowsi- Iserson, & Vavquez, 2007 ). In addition, FICBs have a ness, seizure, cardiovascular compromise) is manda- rapid onset and are as effective as parenteral non- tory, with observations every 5 minutes for 20 minutes. steroidal anti-infl ammatory drugs, which can be haz- All hip fracture patients were included with exclu- ardous in the elderly (Godoy Monzón, Vazquez, sion criteria defi ned as patients with any of the follow- Jauregui, & Iserson, 2010 ). A particular benefi t of ing: international normalized ratio of more than 2.5; FIBC delivery is that it is protective for patients with known sensitivity to local anesthetic; body mass index an intermediate risk of developing postoperative de- of more than 40, previous femoral bypass surgery, or lirium (Mouzopoulos et al., 2009). unable to landmark the femoral artery. Furthermore, Traditionally, regional anesthesia has been per- patients with capacity gave verbal consent for the proce- formed by the anesthetic team. However, in recent dure, with patients who refused being excluded from years, delivery by emergency physicians has been advo- analysis. cated ( Elkhodair et al., 2011 ; Mittal & Vermani, 2014 ). Following the interventions outlined, a retrospec- The authors suggest extending this to include junior tive chart review of 236 patients presenting between clerking doctors (resident doctors) and emergency and April and August 2015 was performed. We detail anesthetic nurse practitioners. FICB utilization rates, dosages of anesthetic used, Although the benefi ts of regional anesthesia are well and documented absence of complications pre- and recognized, receipt is not universally assured for hip frac- postinterventions. ture patients. Indeed, a survey of 230 U.K. EDs found that only 55% gave femoral nerve blocks regularly and 16% oc- casionally by any technique (Mittal & Vermani, 2014). An Results examination of practice at the Royal Devon and Exeter Preintervention, FICB was performed in 40% (n = 51) Hospital demonstrated a suboptimal frequency of FICB de- of eligible patients (ineligible n = 11), with an improve- livery and signifi cant inconsistencies in delivery practices. ment to 72% (n = 160) postintervention (ineligible The aim of this study was to outline measures taken n = 14), see Figures 3a and b. The dose of local anes- to standardize, promote, and improve FICB delivery in thetic used preintervention was inconsistent, ranging hip fracture patients at our institution. from 25 to 125 mg of levobupivacaine. Postintervention, of those who recorded a dose, 98% ( n = 217) followed departmental guidelines using between 75 and 100 mg Methods of 0.25% levobupivacaine. To obtain a baseline, we conducted a retrospective chart Incomplete procedure documentation occurred in review of 138 consecutive patients presenting to the ED all cases preintervention. Postintervention of the 160

186 Orthopaedic Nursing • May/June 2018 • Volume 37 • Number 3 © 2018 by National Association of Orthopaedic Nurses Copyright © 2018 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. F IGURE 2. Proforma used during study to aid individuals delivering fascia iliaca compartment block. Figure developed by authors. procedures, the new proforma was used in 85% (n = versus 65% (n = 144), verbal consent in 9% (n = 11) 136) with full completion in 36% (n = 58). versus 37% (n = 82), absence of generic complications Subsequently, most areas of documentation signiﬁ - in 46% (n = 58) versus 64% (n = 142), and absence of cantly improved pre- versus postintervention, with cli- resistant to injection 4% (n = 5) versus 31% (n = 69; nicians recording aseptic technique in 62% (n = 79) see Table 1 ).

F IGURE 3. Proportion of hip fracture patients receiving FICB pre- and postinterventions. FICB = fascia iliaca compartment block.

© 2018 by National Association of Orthopaedic Nurses Orthopaedic Nursing • May/June 2018 • Volume 37 • Number 3 187 Copyright © 2018 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. the technique can be learned and performed with less TABLE 1. D OCUMENTATION OF PROCEDURES PRE - VERSUS than 5 minutes of instruction. Although we dedicated POSTINTERVENTIONS longer teaching periods for the technique and ensured Preintervention Postintervention close supervision, all those trained readily gained com- Item Documented No. Cases (%) No. Cases (%) petency. Given that FICB is an effective and safe means Number of eligible 127 222 for achieving effective immediate pain control in hip patients fracture patients (Elkhodair et al., 2011; Fletcher, Rigby, Aseptic technique 79 (62) 144 (65) & Heyes, 2003; Godoy Monzon et al., 2007) and the fact that the AAOS continues to advocate FICB as a feasible Absence of 2 (2) 69 (31) contraindications technique in this context (American Academy of Orthopaedic Surgery, 2014 ), training practitioners in Verbal consent 11 (9) 82 (37) safe administration may enhance pain management ap- Absence of generic 58 (46) 142 (64) proaches for this population. The training, close supervi- complications sion, and proforma promoted effective and safe practice, Absence of resistance 5 (4) 69 (31) as well as encouraged comprehensive documentation. In to injection addition, the proforma acted as an aide-memoire of the Absence of signs of 0 69 (31) contraindications and correct local anesthetic dosage, toxicity which is particularly benefi cial to doctors and nurses with less experience performing the procedure. Dose of 95 (75) 217 (98) anesthetic used This study demonstrates that junior doctors, ENPs, and anesthetic nurse practitioners can feasibly deliver FICB in the ED setting. Translation to other environ- No adverse patient outcomes, relating to the inter- ments, such as a ward, cannot be ensured, as the levels of ventions implemented, were recorded during the study supervision may differ. However, given FICB can feasibly period. The new guidance was approved by the clinical be given by emergency medical service nurses in the pre- governance department with no issues subsequently hospital setting, delivery by specialist orthopaedic nurses, raised by clinicians. No diffi culties were encountered in as a means to improving patient care, needs to be ad- training of individuals to deliver FICB by the landmark dressed (Dochez et al., 2014 ). In this regard, further study technique. Close supervision of personnel until they of the delivery of FICB by specialist orthopaedic nurses is were deemed competent ensured that FICBs were being required. delivered safely and with confi dence. Conclusion Discussion Delivery of FICBs by junior doctors, ENPs, and anesthetic nurse practitioners in the ED is feasible, safe, and Three priorities to improve practice were identifi ed, improves the proportion of patients receiving blocks. namely, to increase the frequency of FICB delivery to meet the needs of our patients and service; ensure that REFERENCES correct anesthetic doses were used; and improve the Abrahms , M. S. , Aziz , M. F. , Fu , R. F. , & Horn , J. L . ( 2009 ). procedure documentation. 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