• Anesthesia and analgesia · Sep 2014

    Review Meta Analysis Comparative Study

    Neuraxial Anesthesia for the Prevention of Postoperative Mortality and Major Morbidity: An Overview of Cochrane Systematic Reviews.

    Neuraxial anaesthesia when compared with general anaesthesia may reduce 30 day mortality in patients with intermediate-to-high cardiac risk.

    pearl
    • Joanne Guay, Peter T Choi, Santhanam Suresh, Natalie Albert, Sandra Kopp, and Nathan Leon Pace.
    • From the *Department of Anesthesiology, CSSS Rouyn-Noranda, Rouyn-Noranda, Quebec, Canada; †Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, Canada; ‡Department of Pediatric Anesthesiology and Pediatrics, Northwestern University's Feinberg School of Medicine, Chicago, Illinois; §Department of Anesthesiology, University Laval, Quebec, Canada; ‖Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota; and ¶Department of Anesthesiology, University of Utah, Salt Lake City, Utah.
    • Anesth. Analg.. 2014 Sep 1;119(3):716-25.

    BackgroundThis analysis summarized Cochrane reviews that assess the effects of neuraxial anesthesia on perioperative rates of death, chest infections, and myocardial infarction.MethodsA search was performed in the Cochrane Database of Systematic Reviews on July 13, 2012. We have included all Cochrane systematic reviews that examined subjects of any age undergoing any type of surgical (open or endoscopic) procedure, compared neuraxial anesthesia to general anesthesia alone for the surgical anesthesia, or neuraxial anesthesia plus general anesthesia to general anesthesia alone for the surgical anesthesia, and included death, chest infections, myocardial infarction, and/or serious adverse events as outcomes. Studies included in these reviews were selected on the same criteria.ResultsNine Cochrane reviews were selected for this overview. Their scores on the Overview Quality Assessment Questionnaire varied from 4 to 6 of a maximal possible score of 7. Compared with general anesthesia, neuraxial anesthesia reduced the 0- to-30-day mortality (risk ratio [RR] 0.71; 95% confidence interval [CI], 0.53-0.94; I = 0%) based on 20 studies that included 3006 participants. Neuraxial anesthesia also decreased the risk of pneumonia (RR 0.45; 95% CI, 0.26-0.79; I = 0%) based on 5 studies that included 400 participants. No difference was detected in the risk of myocardial infarction between the 2 techniques (RR 1.17; 95% CI, 0.57-2.37; I = 0%) based on 6 studies with 849 participants. Compared with general anesthesia alone, adding neuraxial anesthesia to general anesthesia did not affect the 0- to-30-day mortality (RR 1.07; 95% CI, 0.76-1.51; I = 0%) based on 18 studies with 3228 participants. No difference was detected in the risk of myocardial infarction between combined neuraxial anesthesia-general anesthesia and general anesthesia alone (RR 0.69; 95% CI, 0.44-1.09; I = 0%) based on 8 studies that included 1580 participants. Adding a neuraxial anesthesia to general anesthesia reduced the risk of pneumonia (RR 0.69; 95% CI, 0.49-0.98; I = 9%) after adjustment for publication bias and based on 9 studies that included 2433 participants. The quality of the evidence was judged as moderate for all 6 comparisons. The quality of the reporting score of complications related to neuraxial blocks was 9 (4 to 12 [median {range}]) for a possible maximum score of 14.ConclusionsCompared with general anesthesia, neuraxial anesthesia may reduce the 0-to-30-day mortality for patients undergoing a surgery with an intermediate-to-high cardiac risk (level of evidence moderate). Large randomized controlled trials on the difference in death and major outcomes between regional and general anesthesia are required.

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    This article appears in the collections: Regional stuff, Meta-analyses, and Neuraxial .

    Notes

    pearl
    1

    Neuraxial anaesthesia when compared with general anaesthesia may reduce 30 day mortality in patients with intermediate-to-high cardiac risk.

    Daniel Jolley  Daniel Jolley
    comment
    0

    This analysis is not practice-changing, but instead highlights our continued lack of understanding of the outcome benefit (or not) of neuraxial versus general anaesthesia in high risk patient groups.

    Interestingly, it is also a meta-analysis of meta-analyses, demonstrating that there are limits to the answers that re-analysing existing data may provide.

    Daniel Jolley  Daniel Jolley
     
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