Femoral Nerve Blockade for Pediatric Femoral Fractures

OBJECTIVES: To evaluate the pediatric femoral nerve block (FNB) utilization for the state of Western Australia, with comparison of a pediatric emergency department (PED) versus general ED settings. To report on contemporary PED FNB procedure and complications for all evaluated cases of FNB. METHODS: A retrospective observational study of cases of femoral fractures presenting directly to or transferred to a PED, from January 1 to December 31, 2022. Variables analyzed included patient demographics, PED episode features, and FNB in transferred patients. Procedural variables included ultrasound (US) guidance, anesthetic agent, dose (mg/kg), pain scales, and adherence to documentation. All cases of FNB were evaluated for complications within 48 hours of admission. RESULTS: In all, 83 cases of femoral fractures were evaluated; 24 (80%) patients received FNB initially in the PED compared with 24 (45.28%) in a general ED before transfer, an odds ratio of 0.21 (95% CI: 0.07, 0.59), P=0.003 for FNB in a general ED compared with a PED was demonstrated. A total of 47 PED FNB procedures were evaluated; median age 3.9 years, median weight 17.0 kg, 35 (74.5%) with US-guidance, ropivacaine was used in all recorded cases, median dose of 1.8 mg/kg, all captured post-procedure pain scales of zero, and documentation adherence was 44.7%. No significant complications were detected. CONCLUSION: There was high adoption of FNB in a PED but poor utilization outside this setting, which cannot be explained by access to a FNB guideline, staffing profile, training or skill mix. Features of the PED FNB procedure included: US-guidance, EM proceduralists, conservative dosing of ropivacaine, and conferring a safe and effective approach. Barriers to practice in general ED settings require addressing, including evidence translation, training, timing, and confidence.