PERIPHERAL NERVE BLOCKADE (PNB)

There were nine high quality studies (Chan 2012, Liu 2014, Sahin 2014, Hinarejos 2016, Ortiz-Gomez 2017, Biswas 2018, Leung 2018, Rousseau-Saines 2018, Dimaculangan 2019) and one low quality study (Wyatt 2015) evaluating whether the use of peripheral nerve blockade reduces complications or improves outcomes in adult patients undergoing knee arthroplasty compared to no peripheral nerve block use. The included literature investigated Femoral Nerve Block (Chan 2012, Sahin 2014, Hinarejos 2016, Ortiz-Gomez 2017, Dimaculangan 2019, Wyatt 2015), Adductor Nerve Block (Leung 2018, Rousseau-Saines 2018, Ortiz-Gomez 2017), Sciatic Block (Liu 2014, Hinarejos 2016), and Lumbar Plexus Block (Liu 2014).

Four high quality studies (Chan 2012, Liu 2014, Hinarejos 2016, Rousseau-Saines 2018) demonstrated significantly lower VAS pain scores, and three high quality studies (Biswas 2018, Rousseau-Saines 2018, Dimaculangan 2019) demonstrated significantly lower opioid requirements during the postoperative period when peripheral nerve blockade was utilized compared to parenteral opioids alone.

Three high quality (Sahin 2014, Biswas 2018, Rousseau-Saines 2018) studies demonstrated no difference in adverse effects (nausea, vomiting, pruritis, urinary retention) between peripheral nerve blockade and no block.

Two high quality (Leung 2018, Dimaculangan 2019) studies and one low quality (Wyatt 2015) study showed no significant difference in early postoperative range of motion compared to no block. However, one high quality study (Chan 2012) demonstrated significantly better overall range-of-motion and a reduction in opioid-related side effects with the use of peripheral nerve blockade when compared to no peripheral nerve block use. Another high quality study (Liu 2014) demonstrated that peripheral nerve block use improved the Quality of Recovery (e.g., Emotive, Nociceptive and Cognitive domains) during the immediate postoperative period.

Benefits/ Harms of Implementation

The risks associated with peripheral nerve blockade may include bleeding, infection, and associated neural injury. Although rare, these potential risks need to be balanced with the documented benefits of peripheral nerve blockade. Depending upon clinical circumstances, peripheral nerve blockade may also be associated with postoperative motor weakness. Under these conditions, care must be taken to minimize the risk of patient falls or delayed mobilization during the hospitalization.

Future Research

Additional prospective studies may be needed to evaluate the long-term (>24-hour) analgesic benefits of peripheral nerve blockade, as well as their impact on functional outcomes. In addition, higher quality studies are also needed to compare specific peripheral nerve block techniques and to compare other modalities of perioperative analgesia (e.g., periarticular injection, neuraxial anesthesia). Future studies comparing the effectiveness of a single perioperative peripheral nerve block versus continuous infusion should be performed for standard outcomes. The scope of this guideline does not include the combination of. Future guidelines should investigate the combination of PNB and Periarticular Local Infiltration (PAI) / Periarticular Block (PAB), as it was not included in the scope of this guideline.