Kopp, Sandra L.

BACKGROUND: This review focuses on the use of peripheral nerve blocks as preoperative analgesia, as postoperative analgesia, or as a supplement to general anesthesia for hip fracture surgery and tries to determine if they offer any benefit in terms of pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction/ischemia, pneumonia, mortality, time to first mobilization, and cost of analgesic. METHODS: Trials were identified by computerized searches of Cochrane Central Register of Controlled Trials (2016, Issue 8), MEDLINE (Ovid SP, 1966 to 2016 August week 1), Embase (Ovid SP, 1988 to 2016 August week 1), and the Cumulative Index to Nursing and Allied Health Literature (EBSCO, 1982 to 2016 August week 1), trials registers, and reference lists of relevant articles. Randomized controlled trials involving the use of nerve blocks as part of the care for hip fractures in adults aged 16 years and older were included. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted the data. The quality of evidence was judged according to the Grading of Recommendations, Assessment, Development, and Evaluations Working Group scale. RESULTS: Based on 8 trials with 373 participants, peripheral nerve blocks reduced pain on movement within 30 minutes of block placement: standardized mean difference, −1.41 (95% confidence interval [CI], −2.14 to −0.67; equivalent to −3.4 on a scale from 0 to 10; I 2 statistic = 90%; high quality of evidence). The effect size was proportional to the concentration of local anesthetic used ( P < .00001). Based on 7 trials with 676 participants, no difference was found in the risk of acute confusional state: risk ratio, 0.69 (95% CI, 0.38–1.27; I 2 statistic = 48%; very low quality of evidence). Based on 3 trials with 131 participants, the risk for pneumonia was decreased: risk ratio, 0.41 (95% CI, 0.19–0.89; I 2 statistic = 3%; number needed-to-treat for additional beneficial outcome, 7 [95% CI, 5–72]; moderate quality of evidence). No difference was found for the risk of myocardial ischemia or death within 6 months but the number of participants included was well below the optimum information size for these 2 outcomes. Based on 2 trials with 155 participants, peripheral nerve blocks also reduced the time to first mobilization after surgery: mean difference, −11.25 hours (95% CI, −14.34 to −8.15 hours; I 2 statistic = 52%; moderate quality of evidence). From 1 trial with 75 participants, the cost of analgesic drugs when used as a single-shot block was lower: standardized mean difference, −3.48 (95% CI, −4.23 to −2.74; moderate quality of evidence). CONCLUSIONS: There is high-quality evidence that regional blockade reduces pain on movement within 30 minutes after block placement. There is moderate quality of evidence for a decreased risk of pneumonia, reduced time to first mobilization, and reduced cost of analgesic regimen (single-shot blocks).

Abstract Background Multimodal analgesia is standard practice for total knee arthroplasty; however, the role of regional techniques in improved perioperative outcomes remains unknown. The authors hypothesized that peripheral nerve blockade would result in lower pain scores and opioid consumption than two competing periarticular injection solutions. Methods This three-arm, nonblinded trial randomized 165 adults undergoing unilateral primary total knee arthroplasty to receive (1) femoral catheter plus sciatic nerve blocks, (2) ropivacaine-based periarticular injection, or (3) liposomal bupivacaine-based periarticular injection. Primary outcome was maximal pain during postoperative day 1 (0 to 10, numerical pain rating scale) in intention-to-treat analysis. Additional outcomes included pain scores and opioid consumption for postoperative days 0 to 2 and 3 months. Results One hundred fifty-seven study patients received peripheral nerve block (n = 50), ropivacaine (n = 55), or liposomal bupivacaine (n = 52) and reported median maximal pain scores on postoperative day 1 of 3, 4, and 4.5 and on postoperative day 0 of 1, 4, and 5, respectively (average pain scores for postoperative day 0: 0.6, 1.7, and 2.4 and postoperative day 1: 2.5, 3.5, and 3.7). Postoperative day 1 median maximal pain scores were significantly lower for peripheral nerve blockade compared to liposomal bupivacaine-based periarticular injection ( P = 0.016; Hodges–Lehmann median difference [95% CI] = −1 [−2 to 0]). After postanesthesia care unit discharge, postoperative day 0 median maximal and average pain scores were significantly lower for peripheral nerve block compared to both periarticular injections (ropivacaine: maximal −2 [−3 to −1]; P < 0.001; average −0.8 [−1.3 to −0.2]; P = 0.003; and liposomal bupivacaine: maximal −3 [−4 to −2]; P < 0.001; average −1.4 [−2.0 to −0.8]; P < 0.001). Conclusions Ropivacaine-based periarticular injections provide pain control comparable on postoperative days 1 and 2 to a femoral catheter and single-injection sciatic nerve block. This study did not demonstrate an advantage of liposomal bupivacaine over ropivacaine in periarticular injections for total knee arthroplasty.

BACKGROUND: Objectives were to determine whether the use of ultrasound guidance offers any clinical advantage in the performance of neuraxial or peripheral nerve blocks in children in terms of increasing the success rate or decreasing the rate of complications. METHODS: We searched the following databases to March 2015: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), EMBASE (OvidSP), and Scopus (to January 2015). We included all parallel randomized controlled trials that evaluated the effect of ultrasound guidance to perform a regional blockade technique in children. We assessed the selected studies for risk of bias with the Cochrane collaboration tool. We graded the level of evidence for each outcome according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group scale. RESULTS: We included 20 studies (1241 participants). Ultrasound guidance increases the success rate by decreasing the occurrence of a failed block: risk difference −0.11 (95% confidence interval [CI], −0.17 to −0.05); I 2 64%; number needed for additional beneficial outcome for peripheral nerve blocks 6 (95% CI, 5–8). The younger the child, the greater the benefit. From 8 studies (414 participants), pain scores at 1 hour in the postanesthesia care unit were reduced when ultrasound guidance was used; however, the clinical relevance of the difference was unclear (equivalent to −0.2 on a scale from 0 to 10). From 8 studies (358 participants), block duration was longer when ultrasound guidance was used: standardized mean difference (SMD) 1.21 (95% CI, 0.76–1.65: I 2 73%; equivalent to 62 minutes). Here again, younger children benefited the most from ultrasound guidance. Time to perform the procedure was reduced when ultrasound guidance was used for prescanning before a neuraxial block (SMD −1.97; 95% CI, −2.41 to −1.54; I 2 0%; equivalent to 2.4 minutes) or as an out-of-plane technique (SMD −0.68; 95% CI, −0.96 to −0.40; I 2 0%; equivalent to 94 seconds). From 2 studies (122 participants), ultrasound guidance reduced the number of needle passes required to perform the block: SMD −0.90 (95% CI, −1.27 to −0.52; I 2 0%; equivalent to 0.6 needle pass per participant). From 2 studies (204 participants), we could not demonstrate a difference in the incidence of bloody puncture when ultrasound guidance was used for neuraxial blockade, but we found that the number of participants was well below the optimal information size (risk difference −0.07, 95% CI, −0.19 to 0.04). No major complications were reported for any of the 1241 participants. We rated the quality of evidence as high for success, pain scores at 1 hour, block duration, time to perform the block, and number of needle passes. We rated the quality of evidence as low for bloody punctures. CONCLUSIONS: Ultrasound guidance seems advantageous, particularly in young children, for whom it improves the success rate and increases block duration. Additional data are required before conclusions can be drawn on the effect of ultrasound guidance in reducing the rate of bloody puncture.