Stop before and after you block

Abstract

Editor—In February 2018, the Royal College of Emergency Medicine (RCEM) published a safety alert regarding death after fascia iliaca blocks (FIBs).1Royal College of Emergency Medicine The importance of monitoring after fascia iliaca block (FIB).2018Date accessed: March 29, 2018Google Scholar This was in response to a coroner's report in which ‘opioid toxicity after administration of a local anaesthetic nerve block’ was listed as the cause of death for a patient who received an FIB for a peri-prosthetic femoral fracture. The report concluded that the patient was not adequately observed after the FIB and that removal of the painful stimulus, as an intended consequence of the FIB, resulted in respiratory arrest because of toxicity from opioids administered before the nerve block. The RCEM safety alert reports poor or no documentation of nerves blocks and inadequate or no post-nerve block observations in the emergency department, and advises that as a minimum the site, side, time, and dose of the nerve block as well as the frequency of post-block observations should be documented. After this safety alert, we conducted an audit looking at opioid administration and nerve block documentation for patients presenting to our emergency department with a fractured neck of femur over the preceding 4 months which identified 41 patients with a mean age of 83 yr who were included in the audit. Of these, 73% received a nerve block—either FIB or femoral, and 67% of these received opioid analgesia in the 4 h before the nerve block either in the pre-hospital setting, the emergency department, or both. All patients given opioids received intravenous morphine (mean dose 8 mg), and 10% received a second opioid, either fentanyl or oxycodone. None of the nerve blocks were documented to the minimum standard advised in the RCEM safety alert, and none of the documented blocks had any mention of frequency of post-procedure observations. These results corroborate the RCEM findings and demonstrate that in this patient group a large proportion receive opioid analgesia before nerve block, putting them at risk of opioid toxicity after the nerve block has been administered. In response to these results, we are now in the process of producing a standardised protocol for administration, documentation, and monitoring of nerve blocks performed in the emergency department at our institution. It varies between institutions which specialty performs FIBs for these patients—usually either the anaesthetics or the emergency team. In the UK, FIBs are often performed by an anaesthetist reviewing the patient in the emergency department or on the ward before theatre, and it is essential that they are aware of this risk and the importance of post-procedure observations and good documentation. On review of the excellent FIB tutorial2Anaesthesia Tutorial of the Week 193 Fascia iliaca compartment block: landmark and ultrasound approach.2010http://www.frca.co.uk/Documents/193%20Fascia%20Iliaca%20compartment%20block.pdfDate accessed: March 29, 2018Google Scholar on the Anaesthesia UK website (www.anaesthesiauk.com), there is no mention of this risk in the complications section and likewise there is no mention of it on the Anaesthesia UK webpage entitled ‘Complications of regional anaesthesia’.3Anaesthesia UK Complications of regional anaesthesia.2005http://www.frca.co.uk/article.aspx?articleid=100508Date accessed: March 29, 2018Google Scholar A review article on peripheral nerve block complications published in the British Journal of Anaesthesia again does not mention the risk of toxicity from opioids administered before the nerve block.4Jeng C.L. Torillo T.M. Rosenblatt M.A. Complications of peripheral nerve blocks.Br J Anaesth. 2010; 105: i107Abstract Full Text Full Text PDF Scopus (179) Google Scholar It therefore appears that this risk has previously gone unrecognised. Anaesthetists, emergency physicians, and others involved in caring for these patients can reduce the risk of potential harm in this already vulnerable patient group and indeed in any patient receiving a peripheral nerve block for acute pain relief. This could easily be achieved by circulation of the RCEM safety alert amongst the anaesthetics community or the issuing of a similar alert by the Royal College of Anaesthetists. Additionally, institutions should ensure they have clear, easily accessible protocols in place for performing, documenting, and monitoring nerve blocks. Avoiding opioid use in patients who may go on to have a peripheral nerve block would eliminate the risk altogether, and suitable non-opioid alternatives such as ketamine or nitrous oxide could be used. Although desirable, this would be difficult to implement in this patient group given the emergency nature of their presentation, initial diagnostic uncertainty, and limited analgesia options often available to pre-hospital teams. The authors declare that they have no conflict of interest.