Epidural analgesia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials
1 Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Commercial Road, Prahran, Melbourne, VIC 3004, Australia
2 Monash University, Melbourne, Australia
* Corresponding author. Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Commercial Road, Prahran, Melbourne, VIC 3004, Australia. E-mail: p.myles{at}alfred.org.au
The relative analgesic efficacy and side-effect profile of peripheral nerve blockade (PNB) techniques compared with lumbar epidural analgesia for major knee surgery is unclear. We undertook a systematic review and meta-analysis of all randomized trials comparing epidural analgesia with PNB for major knee surgery. Eight studies were identified that had enrolled a total of 510 patients of whom 464 (91%) had undergone total knee joint replacement. All were small trials and none was blinded (Jadad score 1–3). PNB technique was variable: in addition to a femoral catheter (n=5), femoral single shot (n=2), or lumbar plexus catheter (n=1) techniques, sciatic blockade was performed in three trials. There was no significant difference in pain scores between epidural and PNB at 0–12 or12–24 h, WMD 0.22 (95% CI: –0.36, 0.81), 0.05 (–1.01, 0.91), respectively, and no clinically significant difference at 24–48 h, WMD –0.35 (–0.64, –0.02). There was also no difference in morphine consumption (mg) at 0–24 h, WMD –6.25 (–18.35, 5.86). Hypotension occurred more frequently among patients who received epidurals [OR 0.19 (0.08, 0.45)], but there was no difference in the incidence of nausea and vomiting. Two studies reported a higher incidence of urinary retention in the epidural group. Patient satisfaction was higher with PNB in two of three studies which measured this, although rehabilitation indices were similar. PNB with a femoral nerve block provides postoperative analgesia which is comparable with that obtained with an epidural technique but with an improved side-effect profile and is less likely to cause a severe neuraxial complication.
Keywords: anaesthetic techniques, epidural; anaesthetic techniques, regional; anaesthetic techniques, regional, knee; complications; surgery, orthopaedic
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