Background Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.
Methods A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.
Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.
The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.
Results Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92).
Conclusions Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.
Recommendation: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.
- nerve block
- regional anesthesia
- acute pain
- treatment outcome
- postoperative complications
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. Systematic review and meta-analysis.
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Contributors SGM had the idea for this article and is the guarantor of this project. A steering committee was formed to design, plan and lead and execute the study throughout the project: SGM, NES, CC, JB, JL, EMS, ERM, RLJ and MJH and GG. The literature search was performed by CC, RG, BJ, LP, BHL, PW, MB, GG, SJK, LB, DSW, GH, and BJ. Data extraction was performed by JB, DB, CC, BHL, PW, MB, GG, SJK, LB, DSW, GH, and BJ. Data analysis was performed by CC, SGM, NES, JP, JB, JL, ES, ERM, RLJ,MH and GG.The manuscript was written by CC, SGM, NES, JP, JB, JL, EMS, ERM, RLJ, MJH, and GG. The following participants reviewed and expanded the study plan, reviewed white papers resulting from quantitative analysis, and contributed to the interpretation of results: VA, EA, MJB, AB, JDA, KE-B, NME, PGautier, PGerner, AGDV, EG, ZG, RH, HK, PK, SK, PL’h, CMacLean, CMantilla, DM, AM, JMN, MP, JParvizi, PP, LPichler, JPoeran, LPoultsides, ESS, BDS, OS, ECS, EV, EGV-V, CLW, JY. All participants reviewed, commented on, and approved the study plan.
Funding This work is a result of solely institutional funding by the Department of Anesthesiology, Critical Care, and Pain Management at the Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
Competing interests SGM is a director on the boards of the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the Society of Anesthesia and Sleep Medicine (SASM). He is a one-time consultant for Sandoz and the holder of US Patent Multicatheter Infusion System. US-2017-0361063. He is the owner of SGM Consulting, LLC and Centauros Healthcare Analytics and Consulting. SGM is also a shareholder in Parvizi Surgical Innovations LLC and HATH. None of the above relations influenced the conduct of the present project.
Provenance and peer review Not commissioned; externally peer reviewed.