Carmen D. Sulton, MD
Emory University School of Medicine
Decatur, Georgia, United States
Pediatric procedural sedation (PPS) is often required for adequate forearm fracture reductions, anxiolysis, and casting for pain control in the pediatric emergency department (PED). Bier blocks (BB) and hematoma blocks (HB) are types of regional anesthesia (RA) procedures which can be performed in the PED as a potential alternative to PPS.
The objective of this study is to compare the safety and efficacy of RA compared to PPS.
This was a retrospective electronic medical record review. PED encounters in patients aged 2-18 years old presenting with a diagnosis of radius fracture, ulna fracture, distal “both bone” fracture, Monteggia fracture, or Galeazzi fracture from 2016 through 2021 were included. Intubated patients, patients not requiring a reduction in the PED, cardiac arrests, American Society of Anesthesiology (ASA) physical status greater than II and patients requiring direct operating room management were excluded. Outcomes of interest included patient adverse events, sedation medications used, PED duration of treatment (arrival time to disposition time), sedation failures, and reduction failures. Sedation failures are defined as emergent anesthesia consult or unplanned inpatient admission. Reduction failures are defined as unacceptable reduction requiring operative intervention.
There were 4206 eligible patient encounters; 3,564 patients underwent PPS and 642 underwent RA. 636 patients received a Bier block and 6 patients received a hematoma block. Propensity matching was performed using a combination of available baseline variables resulting in 632 well matched RA-PPS pairs. Fifty-three percent of patients presented with a radius/ulnar fracture as their primary diagnosis. The average age was 8.1 years for PPS patients and 12 years for RA patients before matching and 12 years in both cohorts after matching. There were 84 total documented adverse events (AEs) in the PPS group and one in the RA group. The most common AE in the PPS group was hypoxia and the only AE in the RA group was an IV infiltrate. The average duration of treatment was 205 minutes in the PPS group and 178 minutes in the RA group (p < 0.001). There were no 72-hour PED returns in either group and no reduction failures.
Bier blocks and hematoma blocks are an acceptable alternative to PPS for children requiring forearm reductions in the PED. The adverse event rate is low and the reduction success rate is high. Duration of treatment in the PED is shorter for patients receiving RA compared to PPS.