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Meta-Analysis
. 2019 May 2;14(5):e0216337.
doi: 10.1371/journal.pone.0216337. eCollection 2019.

Efficacy and safety of femoral nerve block for the positioning of femur fracture patients before a spinal block - A systematic review and meta-analysis

Yuan-Pin Hsu  1   2   3 , Chin-Wang Hsu  1   3 , Karen Chia Wen Chu  1   3 , Wen-Cheng Huang  1   3 , Chyi-Huey Bai  4 , Chun-Jen Huang  2   5 , Sheng-Wei Cheng  2   6 , Jin-Hua Chen  7   8   9 , Chiehfeng Chen  2   4   10   11   12
Affiliations
Meta-Analysis

Efficacy and safety of femoral nerve block for the positioning of femur fracture patients before a spinal block - A systematic review and meta-analysis

Yuan-Pin Hsu et al. PLoS One. .

Abstract

Background: The evidence supporting the benefit of femoral nerve block (FNB) for positioning before spinal anesthesia (SA) in patients suffering from a femur fracture remains inconclusive. In the present study, the authors intended to determine the efficacy and safety of FNB versus an intravenous analgesic (IVA) for positioning before SA in patients with a femur fracture.

Method: PubMed, EMBASE, Cochrane, and Scopus databases were searched up to January 2018. We included randomized controlled studies (RCTs) and observational studies that compared FNB versus IVA for the positioning of patients with femur fracture receiving SA. The primary outcome was pain scores during positioning within 30 min before SA. Secondary outcomes were the time for SA, additional analgesic requirements, anesthesiologist's satisfaction with the quality of positioning for SA, participant acceptance, and hemodynamic changes. A random-effects model was used to synthesize the data. We registered the study at PROSPERO with an ID of CRD42018091450.

Results: Ten studies with 584 patients were eligible for inclusion. FNB achieved significantly lower pain scores than IVA during positioning within 30 min before SA (pooled standardized mean deviation (SMD): -1.27, 95% confidence interval (CI): -1.84 to -0.70, p < 0.05). A subgroup analysis showed that the analgesic effect was larger in patients in the sitting position for SA than a non-sitting position (sitting position vs non-sitting: pooled SMD: -1.75 (p < 0.05) vs -0.61 (not significant). A multivariate regression showed that the analgesic effect was also associated with age and the total equivalent amount as lidocaine after adjusting for gender (age: coefficient 0.048, p < 0.05; total equivalent amount as lidocaine: coefficient 0.005, p < 0.05). Patients receiving FNB also had a significantly shorter time for SA, greater anesthesiologist satisfaction, and higher patient acceptance than patients receiving IVA. The use of local anesthetics did not produce significant clinical hemodynamic change.

Conclusion: Compared to IVA, FNB was an effective and safe strategy for the positioning of femur fracture patients for a spinal block, particularly patients who received SA in the sitting position.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Flow diagram of the search process and search results.
Fig 2
Fig 2. Forest plot of positioning before spinal anesthesia (within 30 min).
Fig 3
Fig 3. Power analysis for meta-analysis.
The power was calculated as 0.9963 based on the anticipated effect size of SMD = 0.8, the 10 identified studies, average of 29 participants per group and high heterogeneity between studies.
Fig 4
Fig 4. Forest plot for comparisons of pain scores during positioning before spinal anesthesia (within 30 min) subgroup by time from intervention to spinal anesthesia.
Fig 5
Fig 5. Meta-regression for standardized mean difference (SMD) of pain scores during positioning for spinal anesthesia between femoral nerve block and intravenous analgesics.
A. The SMD is proportional to the age of the patient. B. The SMD is proportional to the total equivalent amount as lidocaine, i.e., FNB using a low total equivalent amount as lidocaine or use in younger patients was associated with more analgesic effect than IVA after adjusting for gender.
Fig 6
Fig 6. Funnel plots for the comparisons of FNB with IVA on pain scores during positioning.
Standardized mean difference against standard error for 10 simulated studies of varying sample size where there is no publication bias.
Fig 7
Fig 7. Forest plot of time for spinal anesthesia (min).
FNB, femoral nerve block; IVA, intravenous analgesic.
Fig 8
Fig 8. Forest plot of anesthesiologist’s satisfaction with the quality of spinal anesthesia.
FNB, femoral nerve block; IVA, intravenous analgesic.
Fig 9
Fig 9. Forest plot of participant acceptance.
FNB, femoral nerve block; IVA, intravenous analgesic.
Fig 10
Fig 10. Forest plot of additional analgesic requirements.
FNB, femoral nerve block; IVA, intravenous analgesic; CI, confidence interval.
See this image and copyright information in PMC

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