Three part question

In patients [undergoing “3-in-1” nerve block for femoral neck fractures] is [ultrasound scanning as efficatious as nerve stimulation] for [confirmation of needle placement and reducing complications]?

Clinical scenario

A 77 year old woman presents to the emergency department following a simple fall in which she has sustained a fractured neck of femur. You have recently completed a secondment in anaesthetics and consider a “3-in-1” block for pain relief. One of the consultants with whom you worked stated that to perform a nerve block without using a nerve stimulator would be poor clinical practice. When you gave the example of nerve blocks in fractured neck of femur he commented that ultrasound has been used as an alternative to nerve stimulators in this setting.

Search strategy

Medline using Ovid interface 1966–March 2006, CinAHL using Ovid interface 1982 to March Week 2 2006 and Cochrane: via NELH 2006 Issue 1. “femoral and ultrasound and anaesthesia”. Medline: {[(Exp. Ultrasonography or ultrasound$.mp or sonographic guidance.mp) or (electrical nerve stimulator$.mp or electrical nerve stimulation.mp)] and (exp. Nerve block$ or femoral nerve block$.mp or 3-in-1 block.mp or three in one block$.mp or three-in-one block$.mp or triple block.mp or lateral cutaneous nerve block$.mp or obturator nerve block$.mp)} (limited to human, English and abstracts in Medline but not in CinAHL). Cochrane: “femoral and ultrasound and anaesthesia”.

Search outcome

137 papers were found through Medline, of which two were relevant to the three part question (see table 2). No additional papers were found in CinAHL or the Cochrane Librayry.

Cochrane: 21 citations found but no new papers.

Comment(s)

Conformation of needle placement in regional anaesthesia is seen by many as a vital part of the procedure. Many anaesthetists would argue that to perform such procedures without a nerve stimulator is not best practice, and has implications within clinical governance. In the emergency department the use of a nerve stimulator for three-in-one blocks would result in muscular contraction that would cause increase pain and risk fracture displacement. Although the trials are small, the data presented would suggest that ultrasound guide three-in-one block may be an alternative to nerve stimulation in the emergency department.

CLINICAL BOTTOM LINE

Ultrasound guidance is better than electrical nerve stimulation at obtaining a good quality three in one femoral block.