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Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature
  1. Stavros G Memtsoudis1,2,
  2. Crispiana Cozowicz3,
  3. Janis Bekeris3,
  4. Dace Bekere3,
  5. Jiabin Liu1,2,
  6. Ellen M Soffin1,2,
  7. Edward R Mariano4,5,
  8. Rebecca L Johnson6,
  9. George Go1,
  10. Mary J Hargett1,
  11. Bradley H Lee1,2,
  12. Pamela Wendel1,2,
  13. Mark Brouillette1,2,
  14. Sang Jo Kim1,2,
  15. Lila Baaklini1,2,
  16. Douglas S Wetmore1,2,
  17. Genewoo Hong1,2,
  18. Rie Goto1,
  19. Bridget Jivanelli1,
  20. Vassilis Athanassoglou7,
  21. Eriphili Argyra8,
  22. Michael John Barrington9,
  23. Alain Borgeat10,
  24. Jose De Andres11,12,
  25. Kariem El-Boghdadly13,
  26. Nabil M Elkassabany14,
  27. Philippe Gautier15,
  28. Peter Gerner3,
  29. Alejandro Gonzalez Della Valle16,17,
  30. Enrique Goytizolo1,2,
  31. Zhenggang Guo18,
  32. Rosemary Hogg19,
  33. Henrik Kehlet20,
  34. Paul Kessler21,
  35. Sandra Kopp6,
  36. Patricia Lavand'homme22,
  37. Alan Macfarlane23,
  38. Catherine MacLean24,25,
  39. Carlos Mantilla6,
  40. Dan McIsaac26,
  41. Alexander McLawhorn16,17,
  42. Joseph M Neal27,28,
  43. Michael Parks29,
  44. Javad Parvizi30,
  45. Philip Peng31,
  46. Lukas Pichler3,
  47. Jashvant Poeran32,
  48. Lazaros Poultsides33,
  49. Eric S Schwenk34,
  50. Brian D Sites35,
  51. Ottokar Stundner3,36,
  52. Eric C Sun5,
  53. Eugene Viscusi37,
  54. Effrossyni Gina Votta-Velis38,
  55. Christopher L Wu1,2,
  56. Jacques YaDeau1,2 and
  57. Nigel E Sharrock1,2
  1. 1Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
  2. 2Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
  3. 3Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
  4. 4Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
  5. 5Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
  6. 6Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
  7. 7Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  8. 8Faculty of Medicine, Aretaieion University Hospital, Athens, Greece
  9. 9Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
  10. 10Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
  11. 11Anesthesia, Critical Care and Multidisciplinary Pain Management Department, Valencia University General Hospital, Valencia, Spain
  12. 12Anesthesia Unit, Surgical Specialties Department, School of Medicine, University of Valencia, Valencia, Spain
  13. 13Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
  14. 14Anesthesiology and Critical Care, University Of Pennsylvania, Philadelphia, Pennsylvania, USA
  15. 15Department of Anesthesiology and Resuscitation, Clinique Sainte-Anne Saint-Remi, Brussels, Belgium
  16. 16Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
  17. 17Department of Orthopedic Surgery, Weill Cornell Medical College, New York, New York, USA
  18. 18Department of Anesthesiology, Peking Universtiy Shougang Hospital, Beijing, China
  19. 19Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
  20. 20Department of Clinical Medicine, Rigshosp, Copenhagen, Denmark
  21. 21Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Hessen, Germany
  22. 22Anesthesiology, St Luc Hospital, University Catholic of Louvain, Brussels, Belgium
  23. 23School of Medicine, Dentistry & Nursing, Glasgow Royal Infirmary and Stobhill Ambulatory Hospital, Glasgow, UK
  24. 24Center for the Advancement of Value in Musculoskeletal Care, Hospital for Special Surgery, New York, New York, USA
  25. 25Center for the Advancement of Value in Musculoskeletal Care, Weill Cornell Medical College, New York, New York, USA
  26. 26Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
  27. 27Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
  28. 28Benaroya Research Institute, Virginia Mason Medical Center, Seattle, Washington, USA
  29. 29Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
  30. 30Orthopedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
  31. 31Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
  32. 32Orthopaedics/Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  33. 33Department of Orthopaedic Surgery, New York Langone Orthopaedic Hospital, New York, New York, USA
  34. 34Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  35. 35Anesthesiology, Dartmouth Medical School, Hanover, New Hampshire, USA
  36. 36Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Tyrol, Austria
  37. 37Department of Anesthesiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  38. 38Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
  1. Correspondence to Dr Stavros G Memtsoudis, Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, USA; memtsoudiss{at}hss.edu

Abstract

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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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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Footnotes

  • Twitter @sgmemtsoudis, @jbLiujb, @ESoffin, @EMARIANOMD, @rljohnsonmd, @barringtonmj, @elboghdadly, @nelkassabany, @jashvant_p, @ESchwenkMD, @@ChrisWuMD

  • 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.

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