Bupivacaine in the emergency department is underused: scope for improved patient care

Aims: To determine patterns of local anaesthetic use, knowledge and perceived use of local anaesthetic by emergency department doctors, and barriers to bupivacaine use. Methods: This was a multifaceted, observational study undertaken at two large metropolitan emergency departments. It comprised a retrospective chart review of patients who had been given local anaesthetic in the emergency department, an examination of ordering records of local anaesthetics in the emergency department, and a cross-sectional survey of emergency department doctors. Results: The charts of 95 patients were reviewed. Most (93.7%) injuries were lacerations and the most common site was the hand (41.4%). 88 (92.6%), 4 (4.2%) and 3 (3.2%) patients were given lignocaine, prilocaine (Bier’s blocks) and bupivacaine (digital blocks), respectively. Four (4.2%) cases were identified for which bupivacaine was likely to have been a better alternative than the lignocaine used. These were finger/hand injuries likely to be associated with considerable prolonged pain. The emergency deparment pharmacy records indicated that 30 times more lignocaine than bupivacaine was ordered in 2004–5. 30 (88.2%) of 34 doctors completed the survey. Knowledge of local anaesthetic pharmacology was variable: 33% and 66% did not know that bupivacaine was more cardiotoxic and that lignocaine was more painful, respectively. The main barriers to bupivacaine use were “habit” of using lignocaine (46.7%), cardiac toxicity (40%) and slower onset (30%). Conclusion: Bupivacaine seems to be underused in some appropriate circumstances. Accordingly, there is scope for improvement in patient care through critical evaluation of local anaesthetic practice. This is particularly necessary because barriers to bupivacaine use are often non-clinical (habit, availability, familiarity) rather than clinical (toxicity, onset time).