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Neuraxial and Combined Neuraxial/General Anesthesia Compared to General Anesthesia for Major Truncal and Lower Limb Surgery: A Systematic Review and Meta-analysis

Smith, Lauren M. MD*; Cozowicz, Crispiana MD†‡; Uda, Yoshiaki MBBS, FANZCA*; Memtsoudis, Stavros G. MD, PhD†‡; Barrington, Michael J. MBBS, FANZCA, PhD

doi: 10.1213/ANE.0000000000002069
Patient Safety: Systematic Review Article

Neuraxial anesthesia may improve perioperative outcomes when compared to general anesthesia; however, this is controversial. We performed a systematic review and meta-analysis using randomized controlled trials and population-based observational studies identified in MEDLINE, PubMed, and EMBASE from 2010 to May 31, 2016. Studies were included for adult patients undergoing major surgery of the trunk and lower extremity that reported: 30-day mortality (primary outcome), cardiopulmonary morbidity, surgical site infection, thromboembolic events, blood transfusion, and resource use. Perioperative outcomes were compared with general anesthesia for the following subgroups: combined neuraxial-general anesthesia and neuraxial anesthesia alone. Odds ratios (ORs) and 99% confidence intervals (CIs) were calculated to identify the impact of anesthetic technique on outcomes. Twenty-seven observational studies and 11 randomized control trials were identified. This analysis comprises 1,082,965 records from observational studies or databases and 1134 patients from randomized controlled trials. There was no difference in 30-day mortality identified when combined neuraxial-general anesthesia was compared with general anesthesia (OR 0.88; 99% CI, 0.77–1.01), or when neuraxial anesthesia was compared with general anesthesia (OR 0.98; 99% CI, 0.92–1.04). When combined neuraxial-general anesthesia was compared with general anesthesia, combined neuraxial-general anesthesia was associated with a reduced odds of pulmonary complication (OR 0.84; 99% CI, 0.79–0.88), surgical site infection (OR 0.93; 99% CI, 0.88–0.98), blood transfusion (OR 0.90; 99% CI, 0.87–0.93), thromboembolic events (OR 0.84; 99% CI, 0.73–0.98), length of stay (mean difference −0.16 days; 99% CI, −0.17 to −0.15), and intensive care unit admission (OR 0.77; 99% CI, 0.73–0.81). For the combined neuraxial-general anesthesia subgroup, there were increased odds of myocardial infarction (OR 1.18; 99% CI, 1.01–1.37). There was no difference identified in the odds of pneumonia (OR 0.94; 99% CI, 0.87–1.02) or cardiac complications (OR 1.04; 99% CI, 1.00–1.09) for the combined neuraxial-general anesthesia subgroup. When neuraxial anesthesia was compared to general anesthesia, there was a decreased odds of any pulmonary complication (OR 0.38; 99% CI, 0.36–0.40), surgical site infection (OR 0.76; 99% CI, 0.71–0.82), blood transfusion (OR 0.85; 99% CI, 0.82–0.88), thromboembolic events (OR 0.79; 99% CI, 0.68–0.91), length of stay (mean difference −0.29 days; 99% CI, −0.29 to −0.28), and intensive care unit admission (OR 0.50; 99% CI, 0.48–0.53). There was no difference in the odds of cardiac complications (OR 0.99; 99% CI, 0.94–1.03), myocardial infarction (OR 0.91; 99% CI, 0.81–1.02), or pneumonia (OR 0.92; 99% CI, 0.84–1.01). Randomized control trials revealed no difference in requirement for blood transfusion (RR 1.05; 99% CI, 0.65–1.71) and a decreased length of stay (mean difference −0.15 days; 99% CI, −0.27 to −0.04). Neuraxial anesthesia when combined with general anesthesia or when used alone was not associated with decreased 30-day mortality. Neuraxial anesthesia may improve pulmonary outcomes and reduce resource use when compared with general anesthesia. However, because observational studies were included in this analysis, there is a risk of residual confounding and therefore these results should be interpreted with caution.

Supplemental Digital Content is available in the text.Published ahead of print May 19, 2017.

From the *Department of Anaesthesia and Acute Pain Medicine, St. Vincent’s Hospital, Melbourne, Australia; Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York; Department of Anesthesiology, Paracelsus Medical University, Salzburg, Austria; and §Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.

Published ahead of print May 19, 2017.

Accepted for publication February 15, 2017.

Funding: Stavros G. Memtsoudis is funded by the Anna Maria and Stephen Kellen Career Development Award, New York, NY.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

C. Cozowicz and L. M. Smith contributed to this study equally and share first authorship.

Address correspondence to Michael J. Barrington, MBBS, FANZCA, PhD, Department of Anaesthesia and Acute Pain Medicine, St Vincent’s Hospital, Melbourne, Victoria Parade, PO Box 2900, Fitzroy, Victoria 3065, Australia; Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria 3010, Australia. Address e-mail to

© 2017 International Anesthesia Research Society
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