113 Bier Block versus Sedation: A Comparison of Patient Characteristics and Emergency Department Metrics in Pediatric Forearm Reduction

Abstract

Among children presenting to the pediatric emergency department with a forearm fracture requiring closed reduction, the primary objective was to compare the characteristics of children selected for Bier block versus procedural sedation. The secondary objective was to compare procedure-related outcomes for Bier block versus procedural sedation. Children ages 4-16 years old, who presented to a single tertiary-care pediatric emergency department (PED) from 01/2013 to 06/2019 with a forearm fracture requiring reduction were eligible for inclusion in this retrospective cohort study if they underwent Bier block or procedural sedation. Patients with open fractures were excluded. Characteristics of interest included population variables, injury types, and visit-timing factors. Procedure-related outcomes included length of stay, pain scores during and after the procedure, procedure success rates, hospitalization rates and unplanned return visits. 260 children were eligible for inclusion, of whom 177 (68%) underwent Bier Block and 83 (32%) underwent procedural sedation. Children selected for Bier block were more likely to be older (mean 9.5 +/- 3.1 vs. 8.0 +/- 3.4 years, p<0.001), male (128/177[72%] versus 48/83[58%], p=0.020), have fractures involving the radius only (39/177 [22%] versus 8/83[9.6%], p=0.048) and arrive during the weekend (65/177[37%] versus 20/83 [24%], p=0.043) compared with children receiving procedural sedation. However, no characteristics were shown to be predictive of procedure selection based upon a binary regression model (Hosmer-Lemeshow goodness of fit X2=5.069 and p=0.750, Nagelkerke R2 = 0.359). In addition, no differences were identified in procedure selection based on based on race, mechanism of injury, pre-procedure pain scores, presence of underlying medical conditions, hour of arrival, comorbid injuries, or fracture morphology. PED length of stay (220.7 +/- 98.0 vs. 304.0 +/- 134.3 min) and time from procedure to disposition (60.8 +/- 31.9 vs. 91.6 +/- 88.4) were shorter for children who underwent Bier block. Pain scores, reduction success rate, hospitalization rate, and unplanned return visits were similar in both groups. There were differences in the characteristics of children selected for Bier block versus procedural sedation for forearm fracture reduction, but these differences were not predictive of procedure selection. Length of stay was shorter for patients who underwent Bier block, but other procedure-related outcomes were similar.