Guay Joanne, Kopp Sandra
Department of Anesthesiology, Faculty of Medicine, University of Sherbrooke, Sherbrooke, Canada.
Teaching and Research Unit, Health Sciences, University of Quebec in Abitibi-Temiscamingue, Rouyn-Noranda, Canada.
Cochrane Database Syst Rev. 2020 Nov 25;11(11):CD001159. doi: 10.1002/14651858.CD001159.pub3.
This review was published originally in 1999 and was updated in 2001, 2002, 2009, 2017, and 2020. Updating was deemed necessary due to the high incidence of hip fractures, the large number of official societies providing recommendations on this condition, the possibility that perioperative peripheral nerve blocks (PNBs) may improve patient outcomes, and the major role that PNBs may play in reducing preoperative and postoperative opioid use for analgesia.
To compare PNBs used as preoperative analgesia, as postoperative analgesia, or as a supplement to general anaesthesia versus no nerve block (or sham block) for adults with hip fracture. Outcomes were pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction, chest infection, death, time to first mobilization, and costs of an analgesic regimen for single-injection blocks. We undertook the update to look for new studies and to update the methods to reflect Cochrane standards.
For the updated review, we searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 11), in the Cochrane Library; MEDLINE (Ovid SP, 1966 to November 2019); Embase (Ovid SP, 1974 to November 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO, 1982 to November 2019), as well as trial registers and reference lists of relevant articles.
We included randomized controlled trials (RCTs) assessing use of PNBs compared with no nerve block (or sham block) as part of the care provided for adults 16 years of age and older with hip fracture. DATA COLLECTION AND ANALYSIS: Two review authors independently screened new trials for inclusion, assessed trial quality using the Cochrane Risk of Bias-2 tool, and extracted data. When appropriate, we pooled results of outcome measures. We rated the certainty of evidence using the GRADE approach.
We included 49 trials (3061 participants; 1553 randomized to PNBs and 1508 to no nerve block (or sham block)). For this update, we added 18 new trials. Trials were published from 1981 to 2020. Trialists followed participants for periods ranging from 5 minutes to 12 months. The average age of participants ranged from 59 to 89 years. People with dementia were often excluded from the included trials. Additional analgesia was available for all participants. Results of 11 trials with 503 participants show that PNBs reduced pain on movement within 30 minutes of block placement (standardized mean difference (SMD) -1.05, 95% confidence interval (CI) -1.25 to -0.86; equivalent to -2.5 on a scale from 0 to 10; high-certainty evidence). Effect size was proportionate to the concentration of local anaesthetic used (P = 0.0003). Based on 13 trials with 1072 participants, PNBs reduce the risk of acute confusional state (risk ratio (RR) 0.67, 95% CI 0.50 to 0.90; number needed to treat for an additional beneficial outcome (NNTB) 12, 95% CI 7 to 47; high-certainty evidence). For myocardial infarction, there were no events in one trial with 31 participants (RR not estimable; low-certainty evidence). From three trials with 131 participants, PNBs probably reduce the risk for chest infection (RR 0.41, 95% CI 0.19 to 0.89; NNTB 7, 95% CI 5 to 72; moderate-certainty evidence). Based on 11 trials with 617 participants, the effects of PNBs on mortality within six months are uncertain due to very serious imprecision (RR 0.87, 95% CI 0.47 to 1.60; low-certainty evidence). From three trials with 208 participants, PNBs likely reduce time to first mobilization (mean difference (MD) -10.80 hours, 95% CI -12.83 to -8.77 hours; moderate-certainty evidence). One trial with 75 participants indicated there may be a small reduction in the cost of analgesic drugs with a single-injection PNB (MD -4.40 euros, 95% CI -4.84 to -3.96 euros; low-certainty evidence). We identified 29 ongoing trials, of which 15 were first posted or at least were last updated after 1 January 2018. AUTHORS' CONCLUSIONS: PNBs reduce pain on movement within 30 minutes after block placement, risk of acute confusional state, and probably also reduce the risk of chest infection and time to first mobilization. There may be a small reduction in the cost of analgesic drugs for single-injection PNB. We did not find a difference for myocardial infarction and mortality, but the numbers of participants included for these two outcomes were insufficient. Although randomized clinical trials may not be the best way to establish risks associated with an intervention, our review confirms low risks of permanent injury associated with PNBs, as found by others. Some trials are ongoing, but it is unclear whether any further RCTs should be registered, given the benefits found. Good-quality non-randomized trials with appropriate sample size may help to clarify the potential effects of PNBs on myocardial infarction and mortality.
本综述最初发表于1999年，并于2001年、2002年、2009年、2017年和2020年进行了更新。由于髋部骨折的高发病率、众多官方学会针对此病症提供的建议、围手术期外周神经阻滞（PNB）可能改善患者预后的可能性，以及PNB在减少术前和术后用于镇痛的阿片类药物使用方面可能发挥的主要作用，因此认为有必要进行更新。
比较将PNB用作术前镇痛、术后镇痛或全身麻醉补充剂与不对成人髋部骨折患者进行神经阻滞（或假阻滞）的效果。结局指标包括阻滞放置后30分钟的运动时疼痛、急性意识模糊状态、心肌梗死、肺部感染、死亡、首次活动时间以及单次注射阻滞镇痛方案的成本。我们进行此次更新是为了寻找新的研究，并更新方法以符合Cochrane标准。
对于此次更新的综述，我们检索了以下数据库：Cochrane图书馆中的Cochrane对照试验中心注册库（CENTRAL；2019年第11期）；MEDLINE（Ovid SP，1966年至2019年11月）；Embase（Ovid SP，1974年至2019年11月）；护理及相关健康文献累积索引（CINAHL）（EBSCO，1982年至2019年11月），以及试验注册库和相关文章的参考文献列表。
我们纳入了评估PNB使用情况并与不对16岁及以上成人髋部骨折患者进行神经阻滞（或假阻滞）作为护理一部分进行比较的随机对照试验（RCT）。
两名综述作者独立筛选纳入的新试验，使用Cochrane偏倚风险-2工具评估试验质量，并提取数据。在适当情况下，我们汇总了结局指标的结果。我们使用GRADE方法对证据的确定性进行评级。
主要结果：我们纳入了49项试验（3061名参与者；1553名随机分配至PNB组，1508名分配至无神经阻滞（或假阻滞）组）。对于此次更新，我们增加了18项新试验。试验发表于1981年至2020年。试验者对参与者的随访时间从5分钟至12个月不等。参与者的平均年龄在59岁至89岁之间。纳入试验中常排除患有痴呆症的患者。所有参与者均可获得额外的镇痛措施。11项试验共503名参与者的结果显示，PNB可降低阻滞放置后30分钟内的运动时疼痛（标准化均数差（SMD）-1.05，95%置信区间（CI）-
1.25至-0.86；相当于0至10分制中的-2.5分；高确定性证据）。效应大小与所用局部麻醉药的浓度成比例（P = 0.0003）。基于13项试验共1072名参与者的数据，PNB可降低急性意识模糊状态的风险（风险比（RR）0.67，95%CI 0.50至0.90；为获得额外有益结局所需治疗的人数（NNTB）12，95%CI 7至47；高确定性证据）。对于心肌梗死，一项31名参与者的试验中未发生相关事件（RR无法估计；低确定性证据）。在三项共131名参与者的试验中，PNB可能降低肺部感染风险（RR 0.41，95%CI 0.19至0.89；NNTB 7，95%CI 5至72；中等确定性证据）。基于11项试验共617名参与者的数据，由于非常严重的不精确性，PNB对六个月内死亡率的影响尚不确定（RR 0.87，95%CI 0.47至1.60；低确定性证据）。在三项共208名参与者的试验中，PNB可能缩短首次活动时间（均数差（MD）-10.80小时，95%CI -12.83至-8.77小时；中等确定性证据）。一项75名参与者的试验表明，单次注射PNB可能会使镇痛药成本略有降低（MD -4.40欧元，9
5%CI -4.84至-3.96欧元；低确定性证据）。我们确定了29项正在进行的试验，其中15项是在2018年1月1日之后首次发布或至少最后更新的。
PNB可降低阻滞放置后30分钟内的运动时疼痛、急性意识模糊状态的风险，可能还会降低肺部感染风险和首次活动时间。单次注射PNB可能会使镇痛药成本略有降低。我们未发现PNB在心肌梗死和死亡率方面存在差异，但纳入这两个结局指标研究的参与者数量不足。尽管随机临床试验可能并非确定与某项干预措施相关风险的最佳方式，但我们的综述证实了其他人所发现的与PNB相关的永久性损伤风险较低。一些试验正在进行，但鉴于已发现的益处，尚不清楚是否应登记更多随机对照试验。样本量合适的高质量非随机试验可能有助于阐明PNB对心肌梗死和死亡率的潜在影响。
