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BackgroundEvidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.MethodsA systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.ResultsAnalysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92).ConclusionsBased on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.Recommendation: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Neuroprotective effects of dexmedetomidine are reported in preclinical and clinical studies but evidence regarding the postoperative neurocognitive function is not as clear. This study performed a meta-analysis on outcomes of studies which examined neurocognitive performance by using valid assessment tools before and after perioperative dexmedetomidine treatment. Literature was searched in several electronic databases and studies were selected by following précised inclusion criteria. Meta-analyses of mean differences in percent changes from baseline in neurocognitive assessment scores were carried out and subgroup analyses were performed. Eighteen studies were included. Initial dose of dexmedetomidine (mean ± SD) was 1.28 ± 0.97 μg/kg and maintenance dose was 0.41 ± 0.11 μg/kg per hour. In healthy volunteers, there was no significant difference in the neurocognitive performance between dexmedetomidine and controls/comparators (mean difference (95% confidence interval (CI)): -12.72 (-50.25, 24.80) %; P = 0.51). Perioperative dexmedetomidine treatment was associated with significantly better neurocognitive performance in comparison with saline (mean difference (95% CI): 9.10 (3.03, 15.16) %; P = 0.003) as well as with comparator anaesthetics (mean difference: 5.50 (0.15, 10.86) %; P = 0.04) treated patients. In the submeta-analyses of studies which utilized neurocognitive assessment tools other than Mini-Mental State Examination (mean difference: 6.66 (-3.42, 16.74); P = 0.20) or studies with patients under 60 years of age (mean difference: 7.48 (-3.00, 17.96); P = 0.16), the differences were not significant between dexmedetomidine- and saline-/comparator-treated patients. Perioperative dexmedetomidine treatment is associated with significantly better neurocognitive function postoperatively in comparison with both saline controls and comparator anaesthetics (predominantly midazolam).

Introduction:Postoperative delirium is one of the most common and dangerous psychiatric complications after hip surgery. The aim of this study was to investigate the incidence of postoperative delirium in elderly patients after hip fracture surgery and to identify risk factors for such, as part of developing a risk stratification index (RSI) system to predict a patient's risk of postoperative delirium. Methods: Elderly patients (aged 65 years or older) with hip fractures who had received surgical treatment in our hospital between March 2018 and December 2019 were retrospectively included. Clinical data were collected, and multivariate logistic regression analysis was performed to investigate the relevant risk factors of postoperative delirium. An RSI system was developed based on factors identified in the regression analysis. Results: Of 272 patients included, 52 (19.12%) experienced postoperative delirium.Drinking history (> 3/ week), the perioperative lactic acid level (Lac > 2 mmol/L), postoperative visual analog score (VAS) > 3, American Society of Anesthesiologists (ASA) physical status > II, application of the bispectral index, and preoperative diabetes were independent risk factors of postoperative delirium. When RSI ≥ 5, the rate of postoperative delirium significantly increased (p < .05). Conclusion:The RSI system developed here can safely guide postoperative outcomes of elderly patients with hip fractures, and RSI ≥ 5 may be able to predict the onset of postoperative delirium.

We conclude that BMI status needs to be considered for both medical and economic reasons by health care institutions and payers, in order to make prudent decisions in a world where health care expenses are rising rapidly alongside the increasing obesity epidemic, and resources are becoming increasingly scarce.