Ultrasound-guided peripheral nerve blocks for preoperative pain management in hip fractures: a systematic review

Abstract

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.

Effect of early ultrasound-guided femoral nerve block on preoperative opioid consumption in emergency patients with hip fracture: a randomized trial

“…Although previous reviews have already supported the use of ultrasound-guided preoperative nerve blocks, suggesting reduced pain, less need for opioids and a reduced risk of adverse events compared to systemic analgesia, there was no trial considered to have low risk of bias [24,25,35]. Above all, few have examined the effects of a single ultrasound-guided FNB when performed by an emergency physician [18,[26][27][28][29].…”

“…Observational studies suggested that ultrasound-guided FNB was a promising strategy for decreasing pain during the many hours spent in the ED [18,[21][22][23][24]. The level of evidence is low, however, due to the few randomized trials conducted, the high degree of statistical heterogeneity, and some degree of clinical heterogeneity both in the timing of implementation of ultrasound-guided FNB and in the assessment of its effects [24,25]. Finally, randomized trials focused on very short-term pain control (up to 3 h after the procedure) [26,27] or lacked standardized rescue analgesia [28,29].…”

Periphere Regionalanästhesieverfahren – Standards im Wandel?!

“…Vorteil ist sicherlich die deutlich höhere Wahrscheinlichkeit, in vielen Kliniken rund um die Uhr konsiliarisch eine standardisierte, qualitativ hochwertige RA-Technik durch Anästhesisten durchführen zu lassen. Aus den mittlerweile unzähligen Studien zu den verschiedenen Blocktechniken lässt sich eine vergleichbar gute Analgesie gegenüber den Kontrollgruppen mit systemischer Analgesie ermitteln [37]. Eine Cochrane-Analyse erbrachte darüber hinaus Belege für eine geringere Delirquote und möglicherweise eine reduzierte Rate an Pneumonien sowie eine frühzeitige Mobilisationsfähigkeit [38].…”

Improving morbidity and mortality in hip fragility fractures

“…One review article looking at 49 different studies showed that patients that received peripheral nerve blocks had reduction in pain scores, reduced confusion, and reduced time to first mobilization [21]. Another review of 12 trials comparing ultrasound guided blocks to systemic analgesia showed decreased pain, with coinciding decreased morphine equivalent consumption, lower frequency of delirium, and higher patient satisfaction in patients receiving regional anesthesia [22 ▪▪ ]. Local anesthetics have a role outside of the operating room as well; Emergency Medicine physicians have also been evaluating the efficacy of regional anesthesia in hip fractures finding that block patients had less pain with movement, lower opioid requirements, and decreased risk of delirium [23].…”