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. 2014 Jan 25;2014(1):CD010108.
doi: 10.1002/14651858.CD010108.pub2.

Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews

Joanne Guay  1 , Peter Choi, Santhanam Suresh, Natalie Albert, Sandra Kopp, Nathan Leon Pace
Affiliations

Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews

Joanne Guay et al. Cochrane Database Syst Rev. .

Abstract

Background: Various beneficial effects derived from neuraxial blocks have been reported. However, it is unclear whether these effects have an influence on perioperative mortality and major pulmonary/cardiovascular complications.

Objectives: Our primary objective was to summarize Cochrane systematic reviews that assess the effects of neuraxial blockade on perioperative rates of death, chest infection and myocardial infarction by integrating the evidence from all such reviews that have compared neuraxial blockade with or without general anaesthesia versus general anaesthesia alone for different types of surgery in various populations. Our secondary objective was to summarize the evidence on adverse effects (an adverse event for which a causal relation between the intervention and the event is at least a reasonable possibility) of neuraxial blockade. Within the reviews, studies were selected using the same criteria.

Methods: A search was performed in the Cochrane Database of Systematic Reviews on July 13, 2012. We have (1) included all Cochrane systematic reviews that examined participants of any age undergoing any type of surgical (open or endoscopic) procedure, (2) compared neuraxial blockade versus general anaesthesia alone for surgical anaesthesia or neuraxial blockade plus general anaesthesia versus general anaesthesia alone for surgical anaesthesia and (3) included death, chest infection, myocardial infarction and/or serious adverse events as outcomes. Neuraxial blockade could consist of epidural, caudal, spinal or combined spinal-epidural techniques administered as a bolus or by continuous infusion. Studies included in these reviews were selected on the basis of the same criteria. Reviews and studies were selected independently by two review authors, who independently performed data extraction when data differed from one of the selected reviews. Data were analysed by using Review Manager Version 5.1 and Comprehensive Meta Analysis Version 2.2.044.

Main results: Nine Cochrane reviews were selected for this overview. Their scores on the Overview Quality Assessment Questionnaire varied from four to six of a maximal possible score of seven. Compared with general anaesthesia, neuraxial blockade reduced the zero to 30-day mortality (risk ratio [RR] 0.71, 95% confidence interval [CI] 0.53 to 0.94; I(2) = 0%) based on 20 studies that included 3006 participants. Neuraxial blockade also decreased the risk of pneumonia (RR 0.45, 95% CI 0.26 to 0.79; I(2) = 0%) based on five studies that included 400 participants. No difference was detected in the risk of myocardial infarction between the two techniques (RR 1.17, 95% CI 0.57 to 2.37; I(2) = 0%) based on six studies with 849 participants. Compared with general anaesthesia alone, the addition of a neuraxial block to general anaesthesia did not affect the zero to 30-day mortality (RR 1.07, 95% CI 0.76 to 1.51; I(2) = 0%) based on 18 studies with 3228 participants. No difference was detected in the risk of myocardial infarction between combined neuraxial blockade-general anaesthesia and general anaesthesia alone (RR 0.69, 95% CI 0.44 to 1.09; I(2) = 0%) based on eight studies that included 1580 participants. The addition of a neuraxial block to general anaesthesia reduced the risk of pneumonia (RR 0.69, 95% CI 0.49 to 0.98; I(2) = 9%) after adjustment for publication bias and based on nine studies that included 2433 participants. The quality of the evidence was judged as moderate for all six comparisons.No serious adverse events (seizure or cardiac arrest related to local anaesthetic toxicity, prolonged central or peripheral neurological injury lasting longer than one month or infection secondary to neuraxial blockade) were reported. The quality of the reporting score of complications related to neuraxial blocks was nine (four to 12 (median range)) of a possible maximum score of 14.

Authors' conclusions: Compared with general anaesthesia, a central neuraxial block may reduce the zero to 30-day mortality for patients undergoing surgery with intermediate to high cardiac risk (level of evidence, moderate). Further research is required.

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Conflict of interest statement

Joanne Guay: I had no direct relationship with any equipment manufacturer or pharmaceutical company for longer than five years. I hold no stocks or shares other than mutual funds. I did not act as an expert witness for longer than five years. During the last five years, I have received fees as speaker for two lectures given at the University of Dalhousie: one on regional anaesthesia for carotid endarterectomy and the other on local anaesthetic–related methaemoglobinaemia. I am the editor of a multi‐author textbook on anaesthesia (including notions on general and regional anaesthesia). Sandra Kopp: no conflict of interest. Natalie Albert: no conflict of interest. Peter Choi: I have published a prior systematic review included in this Cochrane overview. I have had no participation in judging the quality of my own review or in selecting studies or extracting data from studies pertaining to my review. Nathan Leon Pace: no competing interests. Santhanam Suresh: I have interests in the following: Foundation for Anesthesia Education and Research (FAER) (funded research); Orthopedic Knowledge Online (consultant fees); NIH Sub‐Contract/University of Colorado (funded research); NIH Sub‐Contract, Boston Children’s Hospital (funded research); Sonosite, Inc (equipment support); Philips Healthcare (equipment support); and GE Healthcare (equipment support).

Figures

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1
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
Forest plots for mortality zero to 30 days.
3
3
Forest plots for pneumonia zero to 30 days.
4
4
Forest plots for myocardial infarction zero to 30 days.
See this image and copyright information in PMC

Update of

References

References to included reviews

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