Comparative Efficacy of Neuraxial and General anesthesia for hip fracture surgery: A meta-analysis of randomized clinical trials

Abstract

<jats:title>Abstract</jats:title> <jats:p><jats:bold>Background: </jats:bold>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.<jats:bold>Methods: </jats:bold>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. The sensitivity analyses were performed by the leave-one-out approach. The evidence quality for each outcome was evaluated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.<jats:bold>Results: </jats:bold>Nine randomized controlled trials (RCTs) including 1084 patients fulfilled our selection criteria. The results 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. There was a significant difference in terms of blood loss in favor of the neuraxial anesthesia (MD = -137.8, 95% CI -241.49, -34.12; p = 0.009). The evidence quality for each outcome evaluated by the GRADE system was low.<jats:bold>Conclusions:</jats:bold> In summary, our present study demonstrated that neuraxial anesthesia is associated with a reduced blood loss in patients undergoing hip fracture surgery compared to general anesthesia. However, this result was underpowered. 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</jats:p>

A systematic review and meta-analysis of anesthesia type on hip fracture post-surgery outcomes

“…There is varied and conflicting evidence in the literature regarding the effect of regional anesthesia on mortality in this population. Several meta-analyses published since 2015 have reported no significant differences in 30-day mortality between patients who receive regional or GA [10,13,14] . The current review did not find a significant difference in 30-day mortality but did identify a reduced risk of in-hospital mortality for those receiving regional anesthesia.…”

“…There is varied and conflicting evidence in the literature regarding the effect of regional anesthesia on mortality in this population. Several meta-analyses published since 2015 have reported no significant differences in 30-day mortality between patients who receive regional or GA. [10,13,14] The current review did not find a significant difference in 30-day mortality but did identify a reduced risk of in-hospital mortality for those receiving regional anesthesia. Of note, 2 recent meta-analyses by Chen et al [51] and Van Waesberghe et al [9] reported nearly identical outcomes following hip fracture surgery; they found no differences in 30-day mortality between groups, but reported a decrease of in-hospital mortality when neuraxial anesthesia was used instead of GA. [9,51] Mean length of hospital stay for those undergoing this type of procedure is estimated to be 6.2 days.…”

“…[7] A meta-analysis of similar size (15 RCTs) observed a lower prevalence of deep vein thrombosis and reduced 30-day mortality in the regional anesthesia group; however, the GA group had a significantly reduced operation time. [8] Other metaanalyses have reported no differences in 30-day mortality between patients receiving regional anesthesia or GA. [9,10] Conflicting evidence of varying quality has made it difficult to adopt standard anesthetic recommendations for hip surgery [11,12] ; some relevant meta-analyses report inconsistency in the definition and reporting of certain outcomes, [13,14] while others fail to adequately specify methodology. [15] Therefore, in this meta-analysis, our objective was to provide a rigorous, updated evaluation of the published literature to identify whether anesthesia administration affects mortality following surgical treatment for hip fracture.…”

Proximal femoral fractures

“…Questions could arise if this difference in the percentage of patients operated on with spinal anaesthesia could be of influence on the end result. However, until now the literature is not unambiguous about the advantages and disadvantages of spinal and general anaesthesia in hip fracture patients (46).…”

“…In accordance with some studies (19,42), this reduction was not found in the present study. Other studies showed a reduction of complication rates after the introduction of geriatric co-management, although the percentages and kinds of complications differ per study (43)(44)(45)(46). Also here, a selection or information bias can be created by more thorough examinations by geriatricians compared to surgeons and more detailed patient files.…”