Peripheral nerve blocks for hip fractures

Joanne Guay; Martyn J Parker; Richard Griffiths; Sandra Kopp

doi:10.1002/14651858.CD001159.pub2

Cochrane Database of Systematic Reviews

Bloqueo nervioso periférico para las fracturas de cadera

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DOI:

https://doi.org/10.1002/14651858.CD001159.pub2 Copiar DOI

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Cochrane Database of Systematic Reviews

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11 mayo 2017see what's new

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Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Anestesia

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Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

Joanne Guay

Correspondencia a: Department of Anesthesiology, Faculty of Medicine, University of Sherbrooke, Sherbrooke, Canada

[email protected]

[email protected]
Martyn J Parker

Department of Orthopaedics, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK
Richard Griffiths

Department of Anaesthesia, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK
Sandra Kopp

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, USA

Contributions of authors

Joanne Guay: screened abstracts, search websites, checked reference lists for new articles, selected new articles, retrieved relevant articles, graded articles for risk of bias, extracted data, analysed data, interpreted results, rated quality of evidence and drafted the update.

Martyn Parker: reviewed the update for content before submission.

Richard Griifiiths: reviewed the update for content before submission.

Sandra Kopp: screened abstracts, selected new articles, graded articles for risk of bias, extracted data, interpreted results, rated quality of evidence and drafted the update.

Sources of support

Internal sources

University of Sherbrooke, Canada.

University of Sherbrooke granted access to electronic databases and to major medical journals.
University of Quebec in Abitibi‐Temiscamingue, Canada.

Universiuty of Quebec in Abitibi‐Temiscamingue provided access to electronic databases and medical journals.
Cochrane Anaesthesia, Critical and Emergency Care Group, Denmark.

The review authors wish to thank Karen Hovhannisyan, who designed the search strategy for this update.

External sources

No sources of support supplied

Declarations of interest

Joanne Guay: has no direct relationship with any pharmaceutical company or equipment manufacturer in the past five years. Has not acted as a witness expert in the past five years. Not an author of any of the included or excluded studies. Does not hold any stock other than mutual funds. Editor of a multi‐author textbook on anaesthesia (including notions on general and regional anaesthesia). Receives fees as associate professor for a course on airway management from University of Quebec in Abitibi‐Temiscamingue.

Martyn Parker: has received expenses and honorarium from several commercial companies and organizations for giving lectures on different aspects of hip fracture treatment. Has received royalties from BBrawn Ltd related to design and development of an implant used for internal fixation of intracapsular hip fractures.

Richard Griffiths: chaired Association of Anaesthetists of Great Britain & Ireland guidelines on proximal femoral fracture. Member of National Institute of Health and Care Excellence 124. Chaired Association of Anaesthetists of Great Britain & Ireland guidelines on surgery in the elderly. Founder of NHS Hip Fracture Perioperative Network.

Sandra Kopp: has no conflicts of interest.

Acknowledgements

The review authors thank Karen Hovhannisyan, who designed the search strategy for this update, as well as the University of Sherbrooke and the University of Quebec in Abitibi‐Temiscamingue for granting access to electronic databases and to medical journals.

We thank Harry Scheinin (Scheinin 2000), Fernando Altermatt (Altermatt 2013), Raquel Ortiz de la Tabla González (De La Tabla 2010), Jochen Gille (Gille 2006), K. Sanem Cakar Turhan (Bölükbasi 2013), Ashok Jadon (Jadon 2014) and Hongling Nie (Nie 2015), who provided additional information for the 2015 update, Karl Sales for traduction of two articles (Segado Jimenez 2009; Segado Jimenez 2010); and Gideon Heinert for translation of Gille 2006.

We would also like to thank Stephan Kettner (Content Editor); Jing Xie (Statistical Editor); Fernanda Fukushima, Pekka Tarkkila, Maya Keplinger, Thomas Fichtner Bendtsen and Thomas Dahl Nielsen (Peer Reviewers); and Patricia Tong (Consumer Referee) for help and editorial advice provided during preparation of this systematic review.

Version history

Published

Title

Stage

Authors

Version

2020 Nov 25

Peripheral nerve blocks for hip fractures in adults

Review

Joanne Guay, Sandra Kopp

https://doi.org/10.1002/14651858.CD001159.pub3

2017 May 11

Peripheral nerve blocks for hip fractures

Review

Joanne Guay, Martyn J Parker, Richard Griffiths, Sandra Kopp

https://doi.org/10.1002/14651858.CD001159.pub2

2002 Jan 21

Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures

Review

Martyn J Parker, Richard Griffiths, Bal Appadu

https://doi.org/10.1002/14651858.CD001159

Notes

For the first update (Issue 1, 2001), we made the following changes.

Included study of Chudinov 1999 on psoas compartment blocks.
Changed methods score to include item 8.
Changed statistical analysis to relative risks.
Added a synopsis.

In the second update (Parker 2002), we excluded one newly identified study (Van Leeuwen 2000) and included another (Scheinin 2000a). We have not made changes to the conclusions of the review.

We also updated this review in 2009. At that time, Cochrane updates did not earn a new citation unless they included new review authors or made a change to review conclusions.

For the 2016 update, we made the following changes.

Transferred this review to the Anaesthesia, Critical and Emergency Care Group from the Bone, Joint and Muscle Group.
Included two new review authors.
Updated the search in August 2016.
Updated the review and brought the methods up‐to‐date.
Excluded from the review studies evaluating neuraxial blocks (epidural/spinal) and wound infiltration as techniques of regional blockade.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Aged; Aged, 80 and over; Female; Humans; Male;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Figure 1

Flow diagram for this update.

n: number.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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$Pain on movement in participants with hip fracture between 20 and 30 minutes after block placement. The effect size is proportionate to the concentration of local anaesthetic (mg/mL) used in lidocaine equivalent (P < 0.00001).Local anaesthetic concentration in lidocaine equivalent (calculated as follows: lidocaine = 1, bupivacaine = 4, chloroprocaine = 1.5, dibucaine = 4, etidocaine = 4, levobupivacaine = 3.9, mepivacaine = 0.8, prilocaine = 0.9, procaine = 0.5, ropivacaine = 3 and tetracaine = 4).$

Figure 4

Pain on movement in participants with hip fracture between 20 and 30 minutes after block placement. The effect size is proportionate to the concentration of local anaesthetic (mg/mL) used in lidocaine equivalent (P < 0.00001).

Local anaesthetic concentration in lidocaine equivalent (calculated as follows: lidocaine = 1, bupivacaine = 4, chloroprocaine = 1.5, dibucaine = 4, etidocaine = 4, levobupivacaine = 3.9, mepivacaine = 0.8, prilocaine = 0.9, procaine = 0.5, ropivacaine = 3 and tetracaine = 4).

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Analysis 1.1

Comparison 1 Nerve block versus other modes of analgesia, Outcome 1 Pain on movement within 30 minutes of block placement.

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Analysis 1.2

Comparison 1 Nerve block versus other modes of analgesia, Outcome 2 Pain at rest within 30 minutes after block placement.

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Analysis 1.3

Comparison 1 Nerve block versus other modes of analgesia, Outcome 3 Pain at rest at 6 to 8 hours after surgery.

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Analysis 1.4

Comparison 1 Nerve block versus other modes of analgesia, Outcome 4 Pain on movement at 24 hours after surgery.

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Analysis 1.5

Comparison 1 Nerve block versus other modes of analgesia, Outcome 5 Pain at rest at 24 hours after surgery.

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Analysis 1.6

Comparison 1 Nerve block versus other modes of analgesia, Outcome 6 Pain on movement at 48 hours.

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Analysis 1.7

Comparison 1 Nerve block versus other modes of analgesia, Outcome 7 Pain at rest at 48 hours after surgery.

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Analysis 1.8

Comparison 1 Nerve block versus other modes of analgesia, Outcome 8 Pain at rest at 72 hours after surgery.

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Analysis 1.9

Comparison 1 Nerve block versus other modes of analgesia, Outcome 9 Acute confusional state.

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Analysis 1.10

Comparison 1 Nerve block versus other modes of analgesia, Outcome 10 Pneumonia.

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Analysis 1.11

Comparison 1 Nerve block versus other modes of analgesia, Outcome 11 Mortality.

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Analysis 1.12

Comparison 1 Nerve block versus other modes of analgesia, Outcome 12 Time to first mobilization.

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Analysis 1.13

Comparison 1 Nerve block versus other modes of analgesia, Outcome 13 Costs of analgesic regimens.

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Analysis 1.14

Comparison 1 Nerve block versus other modes of analgesia, Outcome 14 Pressure sores.

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Analysis 1.15

Comparison 1 Nerve block versus other modes of analgesia, Outcome 15 Opioid requirement.

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Analysis 1.16

Comparison 1 Nerve block versus other modes of analgesia, Outcome 16 Participant satisfaction.

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Summary of findings for the main comparison. Peripheral nerve blocks for hip fracture

Peripheral nerve blocks for hip fracture
Patient or population: patients with hip fracture Settings: trials performed in Argentina (n = 1), Austria (n = 1), Chile (n = 1), China (n = 2), Denmark (n = 2), France (n = 2), Geece (n = 3), Germany (n = 1), India (n = 1), Iran (n = 1), Ireland (n = 1), Israel (n = 1), Korea (n = 1), South Africa (n = 1), Spain (n = 2), Sweden (n = 1), Thailand (n = 1), Turkey (n = 2), United Kingdom (n = 5) and United States of America (n = 1) Intervention: peripheral nerve blocks Comparison: systemic analgesia
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Systemic analgesia	Peripheral nerve blocks
Pain on movement at 30 minutes after block placement Follow‐up: 20‐30 minutes		Mean pain on movement at 30 minutes after block placement in the intervention groups was 1.41 standard deviations lower (2.14 to 0.67 lower)		373 (8 studies)	⊕⊕⊕⊕ high^{a,b,c,d,e,f,g,h,i}	Equivalent to ‐ 3.4 on a scale from 0 to 10
Acute confusional state	Study population		RR 0.69 (0.38 to 1.27)	676 (7 studies)	⊕⊝⊝⊝ very low^{c,f,h,j,k,l,m,n}
	198 per 1000	136 per 1000 (75 to 251)
	Low
	150 per 1000	104 per 1000 (57 to 190)
	High
	250 per 1000	172 per 1000 (95 to 317)
Myocardial ischaemia	Study population		RR 0.2 (0.03 to 1.42)	20 (1 study)	⊕⊝⊝⊝ very low^{b,c,j,m,n,o,p,q}
	500 per 1000	100 per 1000 (15 to 710)
	Low
	100 per 1000	20 per 1000 (3 to 142)
	High
	500 per 1000	100 per 1000 (15 to 710)
Pneumonia	Study population		RR 0.41 (0.19 to 0.89)	131 (3 studies)	⊕⊕⊕⊝ moderate^{c,f,h,k,l,n,r,s,t}
	269 per 1000	110 per 1000 (51 to 239)
	Low
	50 per 1000	20 per 1000 (9 to 44)
	High
	200 per 1000	82 per 1000 (38 to 178)
Death Follow‐up: 0‐6 months	Study population		RR 0.72 (0.34 to 1.52)	316 (7 studies)	⊕⊕⊝⊝ low^{c,f,m,n,o,q,s,u}
	98 per 1000	70 per 1000 (33 to 149)
	Low
	25 per 1000	18 per 1000 (9 to 38)
	High
	150 per 1000	108 per 1000 (51 to 228)
Time to first mobilisation		Mean time to first mobilisation in intervention groups was 11.25 hours lower (14.34 to 8.15 lower)		155 (2 studies)	⊕⊕⊕⊝ moderate^{a,c,d,e,h,k,n,p,s,v,w}
Cost of analgesic regimens for single shot blocks		Mean cost of analgesic regimens for single shot blocks in intervention groups was 3.48 standard deviations lower (4.23 to 2.74 lower)		75 (1 study)	⊕⊕⊕⊝ moderate^{a,c,l,n,p,q,s,v}
The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) CI: confidence interval; RR: risk ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Very low quality: We are very uncertain about the estimate
^a50% or more of studies were rated as having unclear or high risk for allocation concealment or blinding of outcome assessor ^bWe did not downgrade the evidence on inconsistency because we found a reasonable explanation for heterogeneity ^cDirect comparisons in studies performed on the population of interest and the outcome measured is not a surrogate marker ^dOptimal information size achieved ^eWide confidence interval around effect size ^fNo evidence of publication bias, or applying a correction for the possibility of one would not modify the conclusion ^gLarge effect size (SMD > 0.8) ^hNo study used ultrasound guidance, which could have increased success rate of blocks ⁱEffect size was proportional to the concentration of local anaesthetic used in lidocaine equivalent ^j75% of studies or more were judged at unclear or high risk of bias for allocation concealment or blinding of outcome assessor ^kModerate amount of heterogeneity or clinical heterogeneity ^lOptimal information size not achieved ^mNo evidence of a large effect ⁿNo evidence of a dose response ^oEstimate included both absence of effect and important benefit ^pCould not be assessed ^qNo evidence of confounding factors that would justify upgrading ^rGroups heterogenous for preoperative characteristics ^sNo heterogeneity or ≤ 25% ^tWe upgraded the level of evidence by one owing to a large effect size (RR < 0.5) ^uWe did not downgrade for risk of bias ^vWe upgraded the level of evidence on the basis of a large effect size (equivalent to SMD > 0.8) ^wWe upgraded the level of evidence on the basis of a large effect size (equivalent to SMD of ‐1.87)

Summary of findings for the main comparison. Peripheral nerve blocks for hip fracture

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Table 1. Anaesthetic techniques

Study	Purpose of blockade	Surgical anaesthesia	Block technique	Comparison
Altermatt 2013	Preoperative and postoperative analgesia	Unspecified	Continuous lumbar plexus with 0.1% bupivacaine in a patient‐controlled analgesia mode	IV morphine
Antonopoulou 2006	Postoperative analgesia	Spinal anaesthesia	Continuous femoral nerve block, nerve stimulator, loaded with 18 mL of 0.25% bupivacaine followed by an infusion of 0.125% levobupivacaine at 3‐4 mL/h	IM pethidine
Beaudoin 2013	Preoperative analgesia	Unspecified	Ultrasound‐guided femoral nerve block performed by an experienced operator with a 7.5 MHz linear probe, participant in Trendelenburg position, cross‐sectional view, 22 G Whitacre needle in‐plane and 25 mL of bupivacaine 0.5% and distal manual pressure for 5 minutes	IM morphine
Chudinov 1999	Preoperative and postoperative analgesia Surgery for some participants	Treatment group: psoas block alone (3/20) with a sciatic block (5/20), a spinal (11/20) or general anaesthesia (1/20) Control group: neuraxial block (19/20) or general anaesthesia (1/20).	Psoas, loss of resistance, Chayen's technique 0.8 mL/kg of bupivacaine 0.25%, operated side up (1 epidural spread)	IM meperidine and diclofenac
Coad 1991	Postoperative analgesia	General anaesthesia for all participants with etomidate, nitrous oxide, enflurane, fentanyl and vecuronium	Lateral cutaneous: 15 mL of 0.5% bupivacaine with epinephrine, Eriksson's technique Femoral (3‐in‐1): 15 mL of 0.5% bupivacaine with epinephrine, Winnie's technique	IM meperidine
Cuvillon 2007	Postoperative analgesia	Spinal anaesthesia for all participants	Continuous femoral nerve block. Nerve stimulator 0.3 to 0.5 mA. Non‐stimulating catheter passed 10‐15 cm past the needle tip loaded with 30 mL of 1.5% lidocaine followed by ropivacaine 0.2% at 10 mL/h for 48 hours	SC morphine
De La Tabla 2010	Preoperative analgesia	Unspecified	Femoral nerve block under dual guidance (ultrasound and nerve stimulator), catheter loaded with 15 mL of ropivacaine 0.2% followed by an infusion of the same solution at 5 mL/h and 10 mL every 30 minutes	IV metamizole and tramadol
Diakomi 2014	Preoperative analgesia (spinal positioning)	Spinal anaesthesia	Fascia iliaca block, Dalen's technique, landmarks, 40 mL of 0.5% ropivacaine	IV fentanyl
Domac 2015	Preoperative analgesia (spinal positioning) plus postoperative analgesia	Spinal anaesthesia	Fascia iliaca block with 15 mL of 0.5% bupivacaine and 15 mL of 2% lidocaine; 2‐3 cm below inguinal ligament at the junction of lateral 1/3 and medial 2/3 of a line from pubis tubercle to anterior iliac spine; 2 pops	IV morphine
Fletcher 2003	Preoperative analgesia	Unspecified	Fermoral (3‐in‐1 nerve block, Wiinie's technique with 20 mL of 0.5% bupivacaine and 5 minutes distal compression)	IV morphine
Foss 2007	Preoperative analgesia	Unspecified	Fascia iliaca block based on Dalen's landmarks with a 24 G blunted needle and 40 mL of 1% mepivacaine with epinephrine	IM morphine
Gille 2006	Preoperative and postoperative analgesia	Treatment group: spinal anaesthesia for 37/50 and general anaesthesia for 13/50 Control group: spinal anaesthesia for 38/50 and general anaesthesia for 12/50	Femoral non‐stimulating catheter: needle 18 G, catheter 20 G (Brown‐Perifix‐Plexus Anaesthesia); 0.5 mA and 0.1 msec. Catheters were advanced about 10 cm past the needle tip and fixed. Loading dose was 40 mL of prilocaine 1% followed 2 hours later by ropivacaine 0.2% 30 mL, repeated every 6 hours. Amount (up to 40 mL; n = 5) and intervals (up to every 4 hours; n = 8) or both (n = 6) adjusted on pain scores	IV metamizole plus oral tilidine and naloxone
Godoy 2010	Preoperative analgesia	Unspecified	Fascia iliaca compartment block, 21G long bevel needle, Dalen's technique with 0.3 mL/kg of 0.25% bupivacaine	IV non‐steroidal anti‐inflammatory drugs
Graham 2008	Preoperative analgesia	Unspecified	Femoral (3‐in‐1) nerve block, Winnie's technique, nerve stimulator and 30 mL of bupivacaine 0.5% (not exceeding 3 mg/kg)	IV morphine
Haddad 1995	Preoperative analgesia	Unspecified	Femoral nerve block with 0.3 mL/kg of bupivacaine 0,25%. Paraesthesia technique with a short bevel needle	IM pethidine, oral co‐dydramol and IM voltarol
Hood 1991	Postoperative analgesia	General anaesthesia for all participants with etomidate, nitrous oxide, isoflurane and alfentanil	Femoral nerve block (triple nerve block) with nerve stimulator < 1.0 mA and 35 mL of prilocaine 0.75% and distal digital pressure plus infiltration above the iliac crest with 8 mL of the same solution	IM papaveratum
Iamaroon 2010	Preoperative analgesia	Spinal anaesthesia	Femoral nerve block with nerve stimulator (0.2 to 0.4 mA) and 20 mL of bupivacaine 0.5% plus 10 mL of saline	IV fentanyl
Jadon 2014	Preoperative analgesia	Spinal anaesthesia	Femoral nerve block with nerve stimulator (0.3 to 0.5 mA) and 15 mL of lidocaine 2% plus 5 mL of distilled water	IV fentanyl
Jones 1985	Postoperative analgesia	General anaesthesia for all participants with thiopental, nitrous oxide, halothane, fentanyl and alcuronium	Lateral cutaneous nerve block with 15 mL of 0.5% bupivacaine, Eriksson's technique	IM pethidine
Kullenberg 2004	Preoperative analgesia	Unspecified	Femoral nerve block with 30 mL of 0.75% ropivacaine. Winnie's approach and nerve stimulator	IM ketobemidon plus tramadol and paracetamol
Luger 2012	Preoperative and postoperative analgesia	Spinal anaesthesia	Ultrasound‐guided femoral (3‐in‐1) nerve block (13‐6 MHz linear probe), catheter inserted ≥ 12‐15 cm past the needle tip) loaded with 30 mL of 0.25% bupivacaine followed by an infusion of 0.125% bupivacaine at 6 mL/h (motor blockade not evaluated) or Lumbar epidural analgesia with 0.125% bupivacaine at 8 mL/h	IV/SC piritramide or IV paracetamol
Mossafa 2005	Preoperative analgesia	Spinal anaesthesia	Fascia iliaca block with 20 mL of 1.5% lidocaine	IV fentanyl
Mouzopoulos 2009	Preoperative and postoperative analgesia	Epidural anaesthesia	Fascia iliaca block daily, Dalen's technique with 0.3 mL/kg of bupivacaine (0.25%?)	IV and analgesics
Murgue 2006	Preoperative analgesia	Unspecified	Femoral nerve block with nerve stimulator and 20 mL of mepivacaine	IV morphine or IV paracetamol and ketoprofen
Nie 2015	Postoperative analgesia	General anaesthesia with propofol, remifentanil and atracurium	Fascia iliaca block with landmarks (2‐3 cm below the inguinal ligament); catheter inserted at least 10 cm cranially and loaded with 20 to 30 mL (weight basis) of 0.5% ropivacaine followed by 0.25% bupivacaine at 0.1 mL/kg/h for 48 hours	IV patient‐controlled analgesia with fentanyl and tropisetron
Segado Jimenez 2009	Postoperative analgesia	Spinal anaesthesia	Landmarks. Obturator nerve with 15 mL of bupivacaine with a vasoconstrictive agent, proximal to the obturator orifice. Femoral lateral cutaneous (Brown) with 10 mL of the same solution	IV morphine
Spansberg 1996	Postoperative analgesia	Spinal anaesthesia	Femoral nerve block with nerve stimulator, non‐stimulating catheter advanced 8‐15 cm past needle tip. Inserted just before surgery. Loaded with 0.4 L/kg of bupivacaine 0.5%; continuous infusion with 0.14 mL/kg/h of bupivacaine 0.25% for 16 hours after surgery	IM morphine
Szucs 2012	Preoperative and postoperative analgesia	Spinal anaesthesia	Non‐stimulating catheter for femoral nerve block, inserted in the emergency department with a nerve stimulator, 0.4 mA and 0.1 msec, space dilated before catheter insertion with 10 mL of 2% lidocaine, catheter advanced 3 cm past the needle tip and 10 mL of 0.5% bupivacaine through the catheter followed by 0.25% bupivacaine infused at 4 mL per hour for 72 hours	IM morphine
Tuncer 2003	Postoperative analgesia	General anaesthesia for all participants with propofol, nitrous oxide, isoflurane, fentanyl, morphine and atracurium	Femoral (3‐in‐1) nerve block, nerve stimulator 0.1 mA, non‐stimulating catheter advanced 4‐5 cm past the needle tip. Loaded with 30 mL of 2% lidocaine with epinephrine followed by an infusion with bupivacaine 0.125% at 4 mL/h for 48 hours	IV morphine
White 1980	Intraoperative analgesia	General anaesthesia with thiopental, nitrous oxide, halothane and fentanyl or nitrous oxide and alfaxolone/alfadolone	Psoas block with 30 mL of 2% mepivacaine, side to be blocked uppermost, Chayen's technique or Spinal: 0.6 to 0.8 mL of hyperbaric cinchocaine	Conventional general anaesthesia
Yun 2009	Preoperative analgesia	Spinal anaesthesia	Fascia iliaca block, Dalen's technique with 30 mL of 0.375% ropivacaine	IV alfentanil
G: gram h: hour IM: intramuscular mA: milliAmpere mcg/mL: microgram/millilitre mg/kg: milligram/kilogram MHz: megahertz mL: millilitre msec: millisecond n: number SC: subcutaneous

Table 1. Anaesthetic techniques

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Table 2. Outcome definitions for acute confusional state

Study	Study authors' definition
Cuvillon 2007	Clinical evaluation "somnolence‐confusion"
Godoy 2010	"episodes of delirium"
Graham 2008	"acute confusional state"
Kullenberg 2004	"transient confusion"
Mouzopoulos 2009	"The primary outcome was perioperative delirium. Diagnosis of the syndrome was defined using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM‐IV), and Confusion Assessment Method (CAM) criteria" "Daily patient assessments using the MMSE, DRS‐R‐ 98, and Digit Span test [assessment of attention, range 0 (no attention) to 42 (good attention)] were used to enable the DSM‐IV and CAM diagnoses and assess delirium severity"
Nie 2015	"Presurgery cognitive status was estimated using the mini‐mental state examination before and after surgery. The Confusion Assessment Method was used to diagnose delirium pre‐ and postsurgery"
White 1980	"confused"

Table 2. Outcome definitions for acute confusional state

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Table 3. Complications of blocks and/or analgesic technique

Study	Complications related to regional anaesthesia	Complications related to analgesic technique
Altermatt 2013	Not reported	Not reported
Antonopoulou 2006	No complications such as motor block. local haematoma or infection, inadvertent arterial puncture, direct nerve damage and cardiovascular or neurological toxicity were observed Five participants had accidental removal or the catheter: 4 during the procedure or while the catheter was secured and 1 while in the ward	Not reported
Beaudoin 2013	No other adverse events were noted during the study period, and no other adverse events were reported to study investigators	Four‐hour oxygen saturation (%) 96 (93–99) vs (%) 98 (95–99) for regional blockade Adverse events: Hypotension, number (%) 3 (17) vs number (%) 0 (0) for regional blockade Respiratory depression, number (%) 9 (50) vs number (%) 4 (22) for regional blockade Nausea/vomiting, number (%) 5 (28) vs number (%) 5 (28) for regional blockade One participant had an episode of rapid atrial fibrillation requiring diltiazem, but the participant had a history of chronic atrial fibrillation
Chudinov 1999	No major complications were described in group regional blockade. Three participants developed local erythema at the catheter insertion site at the end of the study period No signs of local anaesthetic toxicity were documented One participant developed bilateral blockade (L1‐L3 on the opposite side)	Not reported
Coad 1991	No complications related to nerve blocks and no case of prolonged motor blockade	Not reported
Cuvillon 2007	Four catheters were prematurely removed: 1 by a confused participant, 2 by nurses (unexplained fever) and 1 by a surgeon (unconfirmed suspicion of local anaesthetic toxicity (ropivacaine blood level < 2 ng/mL))	More constipation (47% vs 19% for regional blockade)
De La Tabla 2010	Not reported	Not reported
Diakomi 2014	Complications such as local anaesthetic toxicity recorded as well (none reported in results section) Nor did complication rates vary between groups	Complications such as hypoventilation (breathing rate < 8 breaths/min) were recorded as well Moreover, the 2 groups did not differ in these parameters at any time point until study completion at 24 hours after surgery. Nor did complication rates vary between groups
Domac 2015	Not reported	Not reported
Fletcher 2003	Among study participants, none experienced adverse effects as a result of nerve block administration	No clinically important differences between groups with respect to pulse rate, oxygen saturation or respiratory rate at any time interval. Oxygen saturation 94.87%
Foss 2007	No side effects attributable to femoral nerve block were noted in any participants during their hospital stay	More participants (P = 0.05) were sedated in the morphine group at 180 minutes after block placement No difference was noted between groups in nausea and vomiting, with 3 participants in each group having these side effects Tendency toward lower saturation was noted in the opioid group at 60 and 180 minutes after the block despite oxygen supplementation (P = 0.08)
Gille 2006	One inadvertent arterial puncture and blood aspiration positive for 3 participants Two transient paraesthesias No catheter site infection Ten catheters accidentally removed	No respiratory depression from systemic analgesia and no allergic reactions All complications were reversible
Godoy 2010	The only complications were local bruises at the site of injection	Two participants with nausea, and 2 with nausea and vomiting
Graham 2008	No immediate complications occurred in either group	No immediate complications were noted in either group
Haddad 1995	No local or systemic complications of femoral nerve blocks were noted	Not reported
Hood 1991	No untoward sequelae were associated with nerve blocks All plasma prilocaine concentrations (maximum 3 pg/mL) were below the suggested threshold for toxicity for prilocaine of 6 pg/mL	Not reported
Iamaroon 2010	No adverse systemic toxicity of bupivacaine, such as seizure, arrhythmia or cardiovascular collapse was noted in the femoral nerve block group Neither vascular puncture nor paraesthesia occurred No complications, such as haematoma, infection or persistent paraesthesia, were observed within 24 hours after the operation	No participant in either group had hypoventilation (ventilatory rate < 10/min) or oxygen saturation < 95%
Jadon 2014	Not reported	In participants of fentanyl group, drowsiness was observed that required the presence of more persons for holding the participant during positioning SpO₂ was significantly lower in the fentanyl group (P = 0.001). However, no participant in either group had SpO₂ < 90% during the procedure Mean arterial blood pressure was significantly lower in the fentanyl group (P = 0.0019)
Jones 1985	No untoward sequelae associated with the nerve block were seen	Not reported
Kullenberg 2004	No complications related to the nerve blockade were noted in this study	Not reported
Luger 2012	Not reported	Not reported
Mossafa 2005	Not reported	Not reported
Mouzopoulos 2009	No complications of femoral nerve block administrations occurred, except 3 local haematomas developed at the injection site, which resolved spontaneously	Not reported
Murgue 2006	Not reported	Not reported
Nie 2015	No adverse effects, such as pain at the insertion site or paraesthesia, were observed No positive cultures were observed with the fascia iliaca block catheter tip, nor were any signs of infection noted in the current study	Not reported
Segado Jimenez 2009	We did not observe any complications in the realization of regional anaesthetic techniques during or subsequent to the regional anaesthetic techniques	The incidence of side effects (sleepiness, hypotension, constipation, pruritus) was greater in the group with no block than in groups with blocks (P < 0.01)
Spansberg 1996	No haematomas at the site of femoral catheters	Two participants in each group experienced nausea and vomiting
Szucs 2012	For 1 participant, the elastomeric pump failed, resulting in local anaesthetic administered over less than 54 hours instead of 72 hours, and another participant, suffering from acute confusional state, disconnected his pump after 12 hours	The incidence of nausea/vomiting, pruritus or excessive sedation was similar in the 2 groups
Tuncer 2003	Not reported	Side effects (vomiting and pruritus) were observed significantly more frequently with intravenous analgesia
White 1980	No participants showed any evidence of local anaesthetic toxicity	Not reported
Yun 2009	No adverse systemic toxicity of ropivacaine was noted, and neither vascular puncture nor paraesthesia was elicited No complications, such as haematoma or persistent paraesthesia, were observed in participants with a femoral nerve block within 24 hours after the operation	Hypoventilation (ventilatory rate 6–8/min) or pulse oximetric desaturation (oxygen saturation 88% or 89%) was encountered in 4 participants (20%) in the intravenous analgesia group. This was reverted with assisted manual mask ventilation All participants in the intravenous group experienced mild dizziness, and mild drowsiness was present in 12/20 of them
%: percentage L: litre mg: milligram min: minute ng/mL: nanogram/millilitre pg/mL: picogram/millilitre

Table 3. Complications of blocks and/or analgesic technique

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Comparison 1. Nerve block versus other modes of analgesia

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain on movement within 30 minutes of block placement Show forest plot	8	373	Std. Mean Difference (Random, 95% CI)	‐1.41 [‐2.14, ‐0.67]

2 Pain at rest within 30 minutes after block placement Show forest plot	7	322	Std. Mean Difference (Random, 95% CI)	‐0.80 [‐1.25, ‐0.35]

3 Pain at rest at 6 to 8 hours after surgery Show forest plot	5	286	Mean Difference (IV, Random, 95% CI)	‐0.38 [‐0.70, ‐0.06]

4 Pain on movement at 24 hours after surgery Show forest plot	4	195	Mean Difference (IV, Random, 95% CI)	‐0.39 [‐1.08, 0.30]

4.1 Surgical technique unspecified	3	169	Mean Difference (IV, Random, 95% CI)	0.09 [‐0.10, 0.29]
4.2 Arthroplasty for 38.4% of participants	1	26	Mean Difference (IV, Random, 95% CI)	‐1.94 [‐2.75, ‐1.13]
5 Pain at rest at 24 hours after surgery Show forest plot	8	435	Mean Difference (IV, Random, 95% CI)	‐0.68 [‐1.23, ‐0.13]

5.1 Single shot blocks	2	80	Mean Difference (IV, Random, 95% CI)	‐0.5 [‐0.90, ‐0.10]
5.2 Continuous blocks	6	355	Mean Difference (IV, Random, 95% CI)	‐0.78 [‐1.58, 0.03]
6 Pain on movement at 48 hours Show forest plot	2	129	Mean Difference (IV, Fixed, 95% CI)	0.09 [‐0.23, 0.40]

7 Pain at rest at 48 hours after surgery Show forest plot	5	335	Mean Difference (IV, Random, 95% CI)	‐0.37 [‐0.87, 0.13]

7.1 Psoas compartment block	1	40	Mean Difference (IV, Random, 95% CI)	‐1.10 [‐2.26, 0.06]
7.2 Femoral nerve block	3	191	Mean Difference (IV, Random, 95% CI)	0.06 [‐0.16, 0.28]
7.3 Fascia iliaca block	1	104	Mean Difference (IV, Random, 95% CI)	‐0.92 [‐1.47, ‐0.36]
8 Pain at rest at 72 hours after surgery Show forest plot	2	140	Mean Difference (IV, Random, 95% CI)	‐0.48 [‐1.83, 0.87]

8.1 Psoas compartment block	1	40	Mean Difference (IV, Random, 95% CI)	‐1.20 [‐1.77, ‐0.63]
8.2 Femoral nerve block	1	100	Mean Difference (IV, Random, 95% CI)	0.18 [0.03, 0.33]
9 Acute confusional state Show forest plot	7	676	Risk Ratio (M‐H, Random, 95% CI)	0.69 [0.38, 1.27]

9.1 Peripheral nerve block based on landmarks	4	501	Risk Ratio (M‐H, Random, 95% CI)	0.82 [0.23, 2.93]
9.2 Peripheral nerve block based on nerve stimulator	3	175	Risk Ratio (M‐H, Random, 95% CI)	0.56 [0.32, 0.98]
10 Pneumonia Show forest plot	3	131	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.19, 0.89]

11 Mortality Show forest plot	7	316	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.34, 1.52]

12 Time to first mobilization Show forest plot	2	155	Mean Difference (IV, Random, 95% CI)	‐11.25 [‐14.34, ‐8.15]

13 Costs of analgesic regimens Show forest plot	2		Std. Mean Difference (Random, 95% CI)	Subtotals only

13.1 Single shot blocks	1	75	Std. Mean Difference (Random, 95% CI)	‐3.48 [‐4.23, ‐2.74]
13.2 Continuous blocks	1	62	Std. Mean Difference (Random, 95% CI)	0.93 [0.37, 1.48]
14 Pressure sores Show forest plot	3	187	Risk Ratio (M‐H, Random, 95% CI)	0.47 [0.09, 2.53]

14.1 Single shot femoral nerve block (on admission)	2	125	Risk Ratio (M‐H, Random, 95% CI)	0.18 [0.02, 1.38]
14.2 Continous femoral nerve block (after surgery)	1	62	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.19, 4.90]
15 Opioid requirement Show forest plot	7	285	Std. Mean Difference (Random, 95% CI)	‐0.70 [‐0.96, ‐0.44]

15.1 Single shot blocks	5	245	Std. Mean Difference (Random, 95% CI)	‐0.73 [‐1.01, ‐0.44]
15.2 Continuous blocks	2	40	Std. Mean Difference (Random, 95% CI)	‐0.55 [‐1.18, 0.08]
16 Participant satisfaction Show forest plot	5	237	Std. Mean Difference (Random, 95% CI)	0.91 [0.62, 1.20]

Comparison 1. Nerve block versus other modes of analgesia

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Bloqueo nervioso periférico para las fracturas de cadera

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