Peripheral nerve blocks for hip fractures

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

Abstract

Background: Various 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.

Objectives: This 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 methods: For 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 criteria: We 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 analysis: Two 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 results: We 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' conclusions: High-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).

Conflict of interest statement

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.