A Recommendation for Peripheral Nerve Blocks in TJA Patients
To improve outcomes, patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) should receive a peripheral nerve block during the procedure, according to recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group.
The latest recommendations from the ICAROS group are a follow-up to their first recommendations published in 2019. The earlier work examined the impact of the choice of anesthetic technique for surgery and found that neuraxial anesthesia was associated with better outcomes in joint arthroplasty patients compared with general anesthesia. 
The new recommendations address another aspect of regional anesthesia procedures commonly performed for postoperative pain management, namely peripheral nerve blocks. To develop these recommendations, the ICAROS group performed a systematic review and meta-analysis of 122 studies comprising more than 1 million THA and TKA patients. Their goal was to assess how the use of peripheral nerve blocks in these patients correlates to major complications, including mortality and cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.
“This work is of utmost importance as it provides evidence-based recommendations that improve patient outcomes if implemented widely,” said Stavros G. Memtsoudis, MD, PhD, MBA, an anesthesiologist in the Department of Anesthesiology, Critical Care & Pain Management at HSS and leader of the project.
“Currently, only a minority of patients receive these nerve blocks in the setting of joint arthroplasty,” he added, noting that while nearly 99% of patients undergoing TKA at HSS receive a nerve block, the average in the US is only about 1 in 4.
The analysis done by the ICAROS group showed that compared with no peripheral nerve block, use of peripheral nerve blocks during surgery resulted in a significantly lower risk of complications (95% confidence interval), including:
- 70% reduced odds of cognitive dysfunction in THA and 48% in TKA
- 64% reduced odds of respiratory failure in THA and 63% in TKA
- 16% reduced odds of cardiac complications in THA and 17% in TKA
- 45% reduced odds of surgical site infections in THA and 14% in TKA
- 26% reduced odds of thromboembolism in THA and 10% in TKA
- 16% reduced odds of blood transfusion in THA and 14% in TKA
Based on these findings, the ICAROS group strongly recommends that peripheral nerve blocks be used during THA and TKA for improved outcomes, except when contraindications prevent their use. Other factors that should be considered when determining anesthetic techniques include the skills of the providers and the resources available at a given practice location.
“These recommendations are solidly founded on evidence and will hopefully affect change worldwide to improve patient outcomes for millions of patients undergoing hip and knee arthroplasty,” Dr. Memtsoudis said. “It will hopefully also lead to more research, such as which specific nerve blocks are best for which patients.”
Memtsoudis SG, Cozowicz C, Bekeris J, et al. Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature. Reg Anesth Pain Med. 2021;0:1-15. doi:10.1136/rapm-2021-102750
- Memtsoudis SG, Cozowicz C, Bekeris J, et al. Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis. Br J Anaesth. 2019 Sep;123(3):269-287. doi: 10.1016/j.bja.2019.05.042. Epub 2019 Jul 24.