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BACKGROUND: A recent meta-analysis showed that compared with general anesthesia (GA), neuraxial block reduced many serious complications in patients undergoing various types of surgeries. It is not known whether this finding from
studying heterogeneous patient groups is applicable to a particular surgical patient
population. We performed the present meta-analysis to determine whether anesthesia choice affected the outcome after elective total hip replacement (THR).
METHODS: Medline (1966 to August 2005), MD Consult (1966 to August 2005),
BIOSIS (1969 to August 2005), and EMBASE (1969 to August 2005) databases were
searched. Randomized and quasirandomized studies comparing GA and neuraxial
(spinal or epidural) block for elective THR were included in this analysis.
RESULTS: Ten independent trials, involving 330 patients under GA and 348 patients
under neuraxial block, were identified and analyzed. Pooled results from five trials
showed that neuraxial block significantly decreased the incidence of radiographically diagnosed deep venous thrombosis or pulmonary embolism. The odds ratio
(OR) for deep venous thrombosis was 0.27 with 95% confidence interval (CI)
0.17 0.42. The OR for pulmonary embolism was 0.26 with 95% CI 0.12 0.56.
Neuraxial block also decreased the operative time by 7.1 min/case (95% CI 2.311.9
min) and intraoperative blood loss by 275 mL/case (95% CI 180 371 mL). Data
from three trials showed that patients under neuraxial block for THR were less
likely to require blood transfusion than were patients under GA (21/177 12% vs
62/188 33% of patients transfused, P 0.001 by z-test). The OR for this
comparison was 0.26. However, the CIs were wide and compatible with both no
effect and a nine-tenths reduction (95% CI 0.06 1.05).
CONCLUSIONS: Patients undergoing elective THR under neuraxial anesthesia seem to
have better outcomes than those under GA.
(Anesth Analg 2006;103:1018 25)
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Design
Neuraxial General
Outcome
measures
DVT
prophylaxis
Neuraxial
technique
Randomized
prospective
10
Blood loss
Dextran given
postoperatively
Single-injection
epidural
Randomized
prospective
29
31
Operative time,
PE, transfusion
volume, DVT
5000 units sc
heparin from
Day 17
Single-injection
epidural
Quasirandomized
prospective
47
38
Blood loss,
transfusion
volume, DVT
Not noted
Spinal
Randomized
prospective
15
15
None
Continuous
epidural for
24 h
Quasirandomized
prospective
30
30
None
Continuous
epidural for
24 h
Prospective
randomized
48
46
Operative time,
blood loss,
DVT, PE
None
Continuous
epidural for
24 h
Davis (1987,
1989)a(7,16)
Randomized
prospective
69
71
DVT, PE,
hemostatic
markers,
operative time,
blood loss,
patients
transfused
Stockings
Spinal
Randomized
prospective
14
10
Operative time,
blood loss
None
Continuous
epidural for
24 h
Borghi (2002,2005)b
(13,15)
Randomized
prospective
70
70
Hypotension,
bradycardia,
operative time,
intraoperative
blood losses,
patients
transfused
Not noted
Continuous
epidural
Brueckner
(2003) (18)
Randomized
prospective
16
10
Hemostatic
markers,
operative time,
transfusion
volume
Stockings and
low molecular
heparin
(madroparin)
given
preoperatively
Spinal
Davis et al. presented their final results from the same groups of patients in two publications in 1987 and 1989 (7,16).
Borghi et al. reported their findings from the same groups of patients in two papers published in 2002 and 2005 (13,15).
We performed this meta-analysis to test the hypothesis that elective THR under neuraxial block was associated with improved outcomes compared with the
surgery under GA. We focused our analysis on elective
THR to reduce many confounding factors, such as blood
loss before the procedure, in patients with hip fracture
and trauma. We chose to analyze intraoperative outcome measurements including operative time, estimated
intraoperative blood loss, and transfusion requirements
Vol. 103, No. 4, October 2006
METHODS
Medline (1966 to August 2005), MD Consult (1966
to August 2005), BIOSIS (1969 to August 2005), and
EMBASE (1969 to August 2005) databases were independently searched by two authors (WJM and AMS)
2006 International Anesthesia Research Society
1019
estimated intraoperative blood loss, number of patients requiring blood transfusion and the transfusion
volume, operative time, number of patients with DVT
or PE who were diagnosed radiographically, and the
associated mortality. The decision on the suitability of
a study for our analysis and the extracted data by the
two reviewers/authors were compared. Discrepancy
among them was resolved by discussion and reconfirming the data in the original paper. We contacted
the authors if multiple publications on the subject
were from the same authors to verify that the data in
each of the multiple publications were from independent patient groups. Data of continuous parameters
must have been presented in numerical format in the
study to have been included in our analysis, whereas
the data in nontabular format (i.e., bar or line graphs)
were not included, as accurate numbers could not be
assured.
Meta-analysis was performed with the MedCalc
software (Mariakerke, Belgium). Patients who had GA
were treated as control groups, and patients with
neuraxial block were treated as intervention groups.
Odds ratio (OR) and 95% confidence intervals (CI)
were reported for dichotomous outcome parameters.
ANESTHESIA & ANALGESIA
RESULTS
Our search identified 144 publications. Among them,
studies in 14 publications met the inclusion criteria. One
paper reported outcome measures such as pain scores
Vol. 103, No. 4, October 2006
Operative Times
Eight studies reported this outcome. Six of them
showed no statistical difference in operative times
2006 International Anesthesia Research Society
1021
three studies that reported number of patients transfused, one showed that neuraxial block significantly
reduced the number of patients requiring blood transfusion (6). The pooled data from these three studies
demonstrated that fewer patients were transfused
when THR was performed under neuraxial block
(21/177 12% patients) than that under GA
(62/188 33%, P 0.001 by z-test) (Fig. 3, OR 0.26).
However, the CIs were wide and compatible with
both no effect and a nine-tenths reduction (95% CI
0.06 1.05).
Pulmonary Embolism
Five studies presented data on the number of
patients who suffered from a PE evidenced by radiographic or nuclear medicine studies. Three of these
studies showed that neuraxial block significantly decreased the incidence of PE compared with GA (35).
ANESTHESIA & ANALGESIA
DISCUSSION
Our meta-analysis showed statistically significant
reductions in the operative time, intraoperative blood
loss, and the incidence of DVT and PE when neuraxial
blockade was used in a specific patient population:
patients undergoing elective THR. Among the 10
independent studies that contributed data to our
analysis, three studies compared the outcomes between spinal anesthesia and GA (6,7,18), and the
others compared outcomes between epidural anesthesia and GA. In our analysis, we did not separate the
neuraxial block into spinal and epidural block subgroups because of the concern of small sample size for
each subgroup.
Our analysis may have limitations. All the data
included in our analysis are from published studies,
which may have produced biased results. However,
Vol. 103, No. 4, October 2006
1023
Operative Times
Concerns over the use of neuraxial block include a
potentially delayed start time of surgery due to the
placement of the block, failure of the block with
subsequent conversion to GA, and potentially less
than optimal muscle relaxation, which some orthopedic surgeons believe will make the dissection and
placement of the prosthesis more difficult. Our data
indicate a small reduction in the operative time for
elective THR using neuraxial block when compared
with GA. Our data are consistent with a recent Cochrane Report on hip fracture patients by Parker et al.
(19) in which anesthesia choice had a minimal effect
on operative times. Although we were able to show a
statistically significant decrease in operative times
when THR was performed under neuraxial blockade,
the average decrease in duration of 7.1 min/case is
likely not clinically significant.
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