Three Part Question
In [patients with uncomplicated colles' fracture] is [fasting before prilocaine Biers' block] necessary for [the prevention of life threatening complications]?
A 75 year old man presents to the emergency department with a wrist injury. X-ray reveals a Colles' fracture with dorsal angulation requiring manipulation. The patient has had lunch one hour before presentation. Your colleague tells you that you should manipulate the fracture before your shift ends in a hours time, but a passing anaesthetist says that you should wait at least 5 hours (6 hours after food) before you do anything. The departmental manager points out that this means the patient should be admitted since they will "breach" the target time of 4 hours if you wait. If they are admitted the next available trauma list is in 36 hours. You wonder whether the patient should be fasted for 4-6 hours or if it is safe to reduce this fracture under Bier's block without any period of fasting.
Medline 1966-week 3 March 2005 using the OVID interface
Embase 1980-week 13 2005 using the OVID interface
Cochrane Library Issue 1 2005
Medline:[(biers adj block.mp. OR exp nerve block/ OR exp anesthesia, local/ OR exp anesthesia, conduction/)] AND [(exp fasting/ OR fasting.mp.)] Limit to Human and English. 40 papers found
Embase: [biers adj block.mp. OR exp nerve block/ OR exp regional anesthesia/ OR exp intravenous anesthesia/] AND [ exp dietary restriction/ OR exp food deprivation/ OR fasting.mp.] Limit to Human and English. 28 papers
Cochrane :"biers block" [all fields] OR Colles' Fracture (Mesh) AND Fasting (Mesh) 32 articles
50 papers found overall of which 47 were irrelevant to the study question. All the references of the relevant papers were searched and 2 more papers were found. 4 papers are included below:
|Author, date and country
||Study type (level of evidence)
|Bartholomew K and Sloan JP,|
|Patients with colles' fracture reduced under Biers' block anaesthesia||Questionnaire survey to 106 emergency departments||Serious complications||No serious or fatal complications|
|Lowen R and Taylor J,|
|Patients with colles' fracture reduced under Biers' block||Questionnaire survey to 120 emergency departments. 97% response rate||Complications||Convulsions - 2|
|Kendall JM et al,|
|Patients with colles' reduced under Biers' block||Postal survey to 150 emergency departments. 58% response||Complications||No significant adverse effect||Poor response|
|O'Sullivan I et al,|
|Patients with colles' fracture who were treated under Biers' block||Questionnaire survey to 282 emergency departments.77% response||Complications in fasted and unfasted patients||No difference|
The evidence found does not address`the question directly and is limited to the postal surveys. All studies showed that major complications are extremely rare in both groups and, where the question was addressed, there is no evidence of increased rate of complications in patients who were not fasted.
Clinical Bottom Line
The limited evidence available suggests there is no need to fast patients prior to Biers' block. Further research is required.
- Bartholomew K, Sloan JP. Prilocaine for Biers' block; how safe is safe? Arch Emerg Med 1990;7:189-95.
- Lowen R, Taylor J. Biers' block - the experience of Australian emergency departments. Med J Aus 1994;160:108-11.
- Kendall JM, Allen PE, Mccabe SE. A tide of change in the management of an old fracture. J Acc Emerg Med 1995;12:187-8.
- O'Sullivan I, Brooks S, Maryosh J. Is fasting necessary before prilocaine Biers' block? J Acc Emerg Med 1996;13:105-7.