Comparative efficacy of Neuraxial and general anesthesia for hip fracture surgery: a meta-analysis of randomized clinical trials

Abstract

Background: The choice of anesthesia technique remains debatable in patients undergoing surgical repair of hip fracture. This meta-analysis was performed to compare the effect of neuraxial (epidural/spinal) versus general anesthesia on perioperative outcomes in patients undergoing hip fracture surgery. Methods: Medline, Cochrane Library, Science-Direct, and EMBASE databases were searched to identify eligible studies focused on the comparison between neuraxial and general anesthesia in hip fracture patients between January 2000 and May 2019. Perioperative outcomes were extracted for systemic analysis. Sensitivity analyses were conducted using a Bonferroni correction and the leave-one-out method. The evidence quality for each outcome was evaluated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Results: Nine randomized controlled trials (RCTs) including 1084 patients fulfilled our selection criteria. The outcomes for the meta-analysis showed that there were no significant differences in the 30-day mortality (OR = 1.34, 95% CI 0.56, 3.21; P = 0.51), length of stay (MD = − 0.65, 95% CI-0.32, 0.02; P = 0.06), and the prevalence of delirium (OR = 1.05, 95% CI 0.27, 4.00; P = 0.95), acute myocardial infarction (OR = 0.88, 95% CI 0.17, 4.65; P = 0.88), deep venous thrombosis (OR = 0.48, 95% CI 0.09, 2.72; P = 0.41), and pneumonia (OR = 1.04, 95% CI 0.23, 4.61; P = 0.96) for neuraxial anesthesia compared to general anesthesia, and there was a significant difference in blood loss between the two groups (MD = − 137.8, 95% CI-241.49, − 34.12; p = 0.009). However, after applying the Bonferroni correction for multiple testing, all the adjusted p-values were above the significant threshold of 0.05. The evidence quality for each outcome evaluated by the GRADE system was low. Conclusions: In summary, our present study demonstrated that there might be a difference in blood loss between patients receiving neuraxial and general anaesthesia, however, this analysis was not robust to adjustment for multiple testing and therefore at high risk for a type I error. Due to small sample size and enormous inconsistency in the choice of outcome measures, more high-quality studies with large sample size are needed to clarify this issue.

Aspiration pneumonia and anesthesia techniques in hip fracture surgery in elderly patients: A retrospective cohort study using administrative data

“…27,28 Furthermore, recent prospective studies have shown no significant association between the anesthesia method and the incidence of pneumonia or mortality in hip fracture surgery. 29,30 The results of the present study are consistent with the results of these recent reports. In the present study, the frequencies of atelectasis, pneumothorax, and pulmonary edema were very low, and there were no significant differences between the anesthesia groups.…”

“…The results of recent retrospective and prospective studies may support this third reason. [27][28][29][30] Fourth, many elderly patients with hip fractures are frail and suffer from cognitive impairment or chronic constipation. In frail patients, the muscles used to exhale vomit are presumed to be weak.…”

The Effect of General Anesthesia vs. Regional Anesthesia on Postoperative Delirium—A Systematic Review and Meta-Analysis

“…Therefore, the patients undergoing GA are theoretically more likely to develop POD. Unexpectedly, the results of anesthesia mode associated with POD incidence are not consistent based on previous studies ( 11 ). Thus, we performed this systematic review and meta-analysis to clarify the effect of GA vs. RA on the incidence of delirium in adult patients undergoing surgery.…”

“…Therefore, more patients undergoing GA theoretically tend to develop POD. Interestingly, compared with RA, the patients receiving GA did not show significant POD incidence according to some studies ( 11 ).…”

A Comparison of Two Peripheral Nerve Blocks Combined With General Anesthesia in Elderly Patients Undergoing Arthroplasty for Hip Fractures: A Pilot Randomized Controlled Trial

“…Both general anesthesia (GA) and neuraxial anesthesia have been widely used till date. However, meta-analysis studies have failed to demonstrate a significant difference in outcomes with the two methods ( 6 ). While neuraxial anesthesia is preferred for majority patients, it may not be routinely used especially in elderly patients under anticoagulant therapy.…”