Peripheral nerve blocks for hip fractures in adults.
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ABSTRACT:
SUBMITTER: Guay J
PROVIDER: S-EPMC8130997 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundVarious nerve blocks with local anaesthetic agents have been used to reduce pain after hip fracture and subsequent surgery. This review was published originally in 1999 and was updated in 2001, 2002, 2009 and 2017.ObjectivesThis review focuses on the use of peripheral nerves blocks as preoperative analgesia, as postoperative analgesia or as a supplement to general anaesthesia for hip fracture surgery. We undertook the update to look for new studies and to update the methods to reflect Cochrane standards.Search methodsFor the updated review, we searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8), MEDLINE (Ovid SP, 1966 to August week 1 2016), Embase (Ovid SP, 1988 to 2016 August week 1) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to August week 1 2016), as well as trial registers and reference lists of relevant articles.Selection criteriaWe included randomized controlled trials (RCTs) involving use of nerve blocks as part of the care provided for adults aged 16 years and older with hip fracture.Data collection and analysisTwo review authors independently assessed new trials for inclusion, determined trial quality using the Cochrane tool and extracted data. When appropriate, we pooled results of outcome measures. We rated the quality of evidence according to the GRADE Working Group approach.Main resultsWe included 31 trials (1760 participants; 897 randomized to peripheral nerve blocks and 863 to no regional blockade). Results of eight trials with 373 participants show that peripheral nerve blocks reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.41, 95% confidence interval (CI) -2.14 to -0.67; equivalent to -3.4 on a scale from 0 to 10; I2 = 90%; high quality of evidence). Effect size was proportionate to the concentration of local anaesthetic used (P < 0.00001). Based on seven trials with 676 participants, we did not find a difference in the risk of acute confusional state (risk ratio (RR) 0.69, 95% CI 0.38 to 1.27; I2 = 48%; very low quality of evidence). Three trials with 131 participants reported decreased risk for pneumonia (RR 0.41, 95% CI 0.19 to 0.89; I2 = 3%; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 5 to 72; moderate quality of evidence). We did not find a difference in risk of myocardial ischaemia or death within six months, but the number of participants included was well below the optimal information size for these two outcomes. Two trials with 155 participants reported that peripheral nerve blocks also reduced time to first mobilization after surgery (mean difference -11.25 hours, 95% CI -14.34 to -8.15 hours; I2 = 52%; moderate quality of evidence). One trial with 75 participants indicated that the cost of analgesic drugs was lower when they were given as a single shot block (SMD -3.48, 95% CI -4.23 to -2.74; moderate quality of evidence).Authors' conclusionsHigh-quality evidence shows that regional blockade reduces pain on movement within 30 minutes after block placement. Moderate-quality evidence shows reduced risk for pneumonia, decreased time to first mobilization and cost reduction of the analgesic regimen (single shot blocks).
| S-EPMC6481480 | biostudies-literature
Project description:Systematic reviews associate peripheral nerve blocks based on anatomic landmarks or nerve stimulation with reduced pain and need for systemic analgesia in hip fracture patients. We aimed to investigate the effect of ultrasound-guided nerve blocks compared to conventional analgesia for preoperative pain management in hip fractures. Five databases were searched until June 2021 to identify randomised controlled trials. Two independent authors extracted data and assessed risk of bias. Data was pooled for meta-analysis and quality of evidence was evaluated using Grades of Recommendation Assessment, Development and Evaluation (GRADE). We included 12 trials (976 participants) comparing ultrasound-guided nerve blocks to conventional systemic analgesia. In favour of ultrasound, pain measured closest to two hours after block placement decreased with a mean difference of -2.26 (VAS 0 to 10); (p < 0.001) 95% CI [-2.97 to -1.55]. In favour of ultrasound, preoperative analgesic usage of iv. morphine equivalents in milligram decreased with a mean difference of -5.34 (p=0.003) 95% CI [-8.11 to -2.58]. Time from admission until surgery ranged from six hours to more than three days. Further, ultrasound-guided nerve blocks may be associated with a lower frequency of delirium: risk ratio 0.6 (p = 0.03) 95% CI [0.38 to 0.94], fewer serious adverse events: risk ratio 0.33 (p = 0.006) 95% CI [0.15 to 0.73] and higher patient satisfaction: mean difference 25.9 (VAS 0 to 100) (p < 0.001) 95% CI [19.74 to 32.07]. However, the quality of evidence was judged low or very low. In conclusion, despite low quality of evidence, ultrasound-guided blocks were associated with benefits compared to conventional systemic analgesia.
| S-EPMC9210678 | biostudies-literature
Project description: Not available
| S-EPMC6485776 | biostudies-literature
Project description:BackgroundCombined anesthesia can be a promising option for hip surgery when neuraxial anesthesia is contraindicated. Lumbar and sacral plexus blocks, and femoral nerve and lateral femoral cutaneous (LFC) nerve blocks in combination with general anesthesia (GA) are commonly used in elderly patients undergoing arthroplasty for hip fracture surgery. However, no study has compared these two anesthetic strategies in the perioperative period.MethodsA total of 41 elderly patients scheduled for arthroplasty for hip fracture surgery were randomized into group A (n = 20) and group B (n = 21). Group A received femoral nerve block, LFC nerve blocks, and GA, and group B received lumbar plexus block, sacral plexus block, and GA. Primary outcomes were incidences of hemodynamic events and changes in blood pressure (BP) and heart rate (HR). Secondary outcomes included time and drug consumption, infusion and bleeding volume, eyes opening time after surgery, and postoperative quality recovery rate.ResultsCompared with group B, group A showed a lower incidence of intraoperative hypotension (p < 0.001), higher BP [including mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP (DBP)] following induction (IN), and higher HR from mid-surgery. Time required for nerve blockade (p < 0.001) and ephedrine consumption was significantly shorter in group A (p < 0.001), while sufentanil consumption was higher as compared to group B (p = 0.002). No significant differences in other intraoperative parameters and postoperative quality recovery rate were reported during the observation.ConclusionOur pilot data indicate that compared with lumbar and sacral plexus blocks, femoral nerve and LFC nerve blocks may provide more stable intraoperative hemodynamics and a comparable postoperative recovery for elderly patients undergoing arthroplasty for hip fracture under GA. Further studies with a larger sample size are needed to derive stronger evidence.
| S-EPMC8891216 | biostudies-literature
Project description: Not available
| S-EPMC10835205 | biostudies-literature
Project description:Peripheral nerve blocks have a unique role in postcesarean delivery multimodal analgesia regimens. In this review article, options for peripheral nerve blocks for cesarean delivery analgesia will be reviewed, specifically paravertebral, transversus abdominis plane, quadratus lumborum, iliohypogastric and ilioinguinal, erector spinae, and continuous wound infiltration blocks. Anatomy, existing literature evidence, and specific areas in need of future research will be assessed. Considerations for local anesthetic toxicity, and for informed consent for these modalities in the context of emergency cesarean deliveries, will be presented.
| S-EPMC7182469 | biostudies-literature
Project description:BackgroundDisplaced intracapsular hip fractures are typically treated with hemiarthroplasty (HA) or total hip arthroplasty (THA). A number of professional bodies recommend considering THA for patients that were independently mobile and cognitively intact before injury. The aim of this study was to compare the outcomes between HA and THA for independently mobile older adults with hip fractures.MethodsA systematic review and meta-analysis of RCTs was undertaken alongside analysis of a propensity score matched national cohort of older adults (aged > 60) with hip fractures. Participants were identified for the propensity score matched cohort from the National Hip Fracture Database (NHFD), which was linked to Hospital Episode Statistics (HES) and civil death registration data. The primary outcomes were 12-month dislocation, revision, and mortality. The secondary outcomes were length of stay, discharge home, unplanned re-admission, functional outcomes, and health-related quality of life.ResultsFive RCTs reported higher THA dislocation but this was not statistically significant (THA risk ratio [RR] 2.77, 95% CI 0.81 to 9.48). However, THA dislocation was significantly higher in the national observational dataset (sub-distribution hazard ratio [SHR] 1.73, 95% CI 1.24 to 2.41). Meta-analysis of data from four RCTs did not identify a significant difference in terms of revision (RR 1.52, 95% CI 0.56 to 4.14). However, THA revision was significantly lower in the national dataset (SHR 0.66, 95% CI 0.48 to 0.90). Meta-analysis of data from 5 RCTs suggested higher mortality amongst patients undergoing HA (RR 0.63, 95% CI 0.38 to 1.04), which was also observed within the national registry dataset (hazard ratio 0.45, 95% CI 0.37 to 0.54).ConclusionsNational clinical registries can provide important context when interpreting RCT data, which may alone be inadequate for comparing the safety profile of surgical interventions. These data suggest that THA is at significantly higher risk of dislocation but lower risk of revision within 12 months. The finding from both RCT and clinical registry data that THA is associated with lower 12-month mortality amongst the fittest patients with hip fractures requires urgent further study to determine whether or not this can be replicated in other balanced populations.
| S-EPMC6525472 | biostudies-literature
Project description:Cervical plexus nerve blocks have been employed in various head and neck operations. Both adequate anaesthesia and analgesia are attained in clinical practice. Nowadays, ultrasound imaging in regional anaesthesia is driven towards a certain objective that dictates high accuracy and safety during the implementation of peripheral nerve blocks. In the cervical region, ultrasound-guided nerve blocks have routinely been conducted only for the past few years and thus only a small number of publications pervade the current literature. Moreover, the sonoanatomy of the neck, the foundation stone of interventional techniques, is very challenging; multiple muscles and fascial layers compose a complex of compartments in a narrow anatomic region, in which local anaesthetics are injected. Therefore, this review intends to deliver new insights into ultrasound-guided peripheral nerve block techniques in the neck. The sonoanatomy of the cervical region, in addition to the cervical plexus, cervical ganglia, superior and recurrent laryngeal nerve blocks are comprehensively discussed.
| S-EPMC7719858 | biostudies-literature
Project description:Background: Peripheral nerve block (PNB) has been shown to be safe and effective, and its use has continued to increase, but it is not without risks. One potentially preventable risk is wrong-site blocks (WSBs). Our institution mandated a time-out process before PNB in 2003, and then in 2007 made two more changes to our policy to mitigate risk: (1) the circulating/block nurse was the only person permitted to access the block needles; after a time-out period was complete, the nurse gave the needles to the anesthesiologist; and (2) the nurse remained at the patient's bedside until the PNB was initiated. Purpose: We sought to compare the incidence of WSBs before and after this time-out process was implemented in 2003 and the enhanced form of it was implemented in 2007. We hypothesized that the enhanced process would decrease the incidence of WSBs. Methods: We retrospectively analyzed data, from January 2003 to December 2016, taken from the quality assurance and performance improvement (QA/PI) division of the anesthesiology department at our institution, which maintained daily statistics on anesthetic types using quality audits from paper or electronic anesthesia records. All WSBs from this period were reported to the QA/PI division and root cause analyses performed. The incidence of WSB was compared pre- and post-implementation of the enhanced time-out policy for upper extremity, lower extremity, and all blocks by calculating relative risks with 95% score confidence intervals and performing Fisher's exact tests. Results: The incidence of WSBs decreased from 1.10/10,000 before changes to the policy were initiated to 0.24/10,000 afterward. Conclusion: We observed an association between the implementation of a dynamic, team-focused time-out process and a reduction in the incidence of WSBs at our institution. A causal effect of the enhanced time-out cannot be determined given the risk of bias associated with before-after study designs and our lack of adjustment for potential confounders. Further research is therefore warranted.
| S-EPMC8361586 | biostudies-literature
Project description:Fractures in and around the hip are common presentations in the emergency department. It is commonly seen in the elderly as a result of osteoporotic changes. However, younger age groups are also affected, especially as a result of high velocity trauma. Irrespective of age, hip fractures are extremely painful, and it is difficult to position the patients for anesthesia procedures. Most of these cases are performed under subarachnoid block (SAB) or combined spinal-epidural anesthesia (CSEA), which requires the patient to be in sitting or lateral position. Here, we report a series of ten cases where pericapsular nerve group (PENG) block was administered prior to positioning the patients for SAB or CSEA. This block is a recently described regional anesthesia technique that provides excellent analgesia for hip fractures. It also provides very good analgesia for patient positioning during procedures such as SAB or CSEA.
| S-EPMC7091518 | biostudies-literature