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Cochrane Database of Systematic Reviews

Les blocs nerveux périphériques pour les fractures de la hanche

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DOI:
https://doi.org/10.1002/14651858.CD001159.pub2Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 11 mayo 2017see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:
  1. Grupo Cochrane de Anestesia

Copyright:
  1. 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.

  1. Included study of Chudinov 1999 on psoas compartment blocks.

  2. Changed methods score to include item 8.

  3. Changed statistical analysis to relative risks.

  4. 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.

  1. Transferred this review to the Anaesthesia, Critical and Emergency Care Group from the Bone, Joint and Muscle Group.

  2. Included two new review authors.

  3. Updated the search in August 2016.

  4. Updated the review and brought the methods up‐to‐date.

  5. Excluded from the review studies evaluating neuraxial blocks (epidural/spinal) and wound infiltration as techniques of regional blockade.

Keywords

MeSH

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.

Flow diagram for this update.n: number.
Figuras y tablas -
Figure 1

Flow diagram for this update.

n: number.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 2

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

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 3

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

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).
Figuras y tablas -
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).

Comparison 1 Nerve block versus other modes of analgesia, Outcome 1 Pain on movement within 30 minutes of block placement.
Figuras y tablas -
Analysis 1.1

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 2 Pain at rest within 30 minutes after block placement.
Figuras y tablas -
Analysis 1.2

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 3 Pain at rest at 6 to 8 hours after surgery.
Figuras y tablas -
Analysis 1.3

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 4 Pain on movement at 24 hours after surgery.
Figuras y tablas -
Analysis 1.4

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 5 Pain at rest at 24 hours after surgery.
Figuras y tablas -
Analysis 1.5

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 6 Pain on movement at 48 hours.
Figuras y tablas -
Analysis 1.6

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 7 Pain at rest at 48 hours after surgery.
Figuras y tablas -
Analysis 1.7

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 8 Pain at rest at 72 hours after surgery.
Figuras y tablas -
Analysis 1.8

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 9 Acute confusional state.
Figuras y tablas -
Analysis 1.9

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 10 Pneumonia.
Figuras y tablas -
Analysis 1.10

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 11 Mortality.
Figuras y tablas -
Analysis 1.11

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 12 Time to first mobilization.
Figuras y tablas -
Analysis 1.12

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 13 Costs of analgesic regimens.
Figuras y tablas -
Analysis 1.13

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 14 Pressure sores.
Figuras y tablas -
Analysis 1.14

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 15 Opioid requirement.
Figuras y tablas -
Analysis 1.15

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

Comparison 1 Nerve block versus other modes of analgesia, Outcome 16 Participant satisfaction.
Figuras y tablas -
Analysis 1.16

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

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)

⊕⊕⊕⊕
higha,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 lowc,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 lowb,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)

⊕⊕⊕⊝
moderatec,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)

⊕⊕⊝⊝
lowc,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)

⊕⊕⊕⊝
moderatea,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)

⊕⊕⊕⊝
moderatea,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)

Figuras y tablas -
Summary of findings for the main comparison. Peripheral nerve blocks for hip fracture
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

Figuras y tablas -
Table 1. Anaesthetic techniques
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"

Figuras y tablas -
Table 2. Outcome definitions for acute confusional state
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

Figuras y tablas -
Table 3. Complications of blocks and/or analgesic technique
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]

Figuras y tablas -
Comparison 1. Nerve block versus other modes of analgesia