Standards of practice for peripheral nerve blocks at a tertiary care center in a low-middle income country- a prospective observational study.

Abstract

Background: Peripheral nerve blocks (PNB) have gained tremendous interest as a means of providing anesthesia and analgesia. Heterogeneity exists in the standards of practice (SoP) for PNB, especially in resource limited settings. Therefore, this study aimed to determine the SoP for administration of PNB at a tertiary care, University teaching hospital, in a low-middle income country (LMIC).

Methods: This was a prospective observational study conducted between September 2021 and March 2023. The SoP were collected through either direct or indirect observation, using a self-developed proforma. Data were collected for various domains and were mapped to structure, process and outcome. They were then benchmarked to identify best practices and deficiencies.

Results: A total of 386 PNBs were recorded, of which 196 (50.8%) were directly observed. Majority were administered to low-risk individuals without comorbidities (61.9%). In the structure metrics resuscitation equipment was available in 76% while availability of resuscitation drugs (29%) was identified as needing improvement. Individual components of process metrics such as intravenous access, use of personal protective equipment, ultrasound guided block technique and use of short bevel needles exceeded the 95% benchmark, while components such as monitoring (54%), aseptic site preparation (76.5%), the Stop Before You Block procedure (61.9%) and use of block additives (70.2%) fell short of the benchmark. Postoperative multimodal analgesia prescription (4.7%) was identified as needing improvement. Of the outcome metrics, while immediate post-block complications (0%) and conversion rate to general anesthesia (8.3%) exceeded the benchmark (< 10%), cumulative toxic dose was exceeded (36.6%) when a mixture of local anesthetics was used.

Conclusion: Standards of practice for structure, process and outcome were partly achieved for PNB at this tertiary care center in a low-middle income country. Strategies to improve SoP have been proposed and will need to be evaluated in future quality improvement initiatives.