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Meta-Analysis
. 2016 Feb 22;2(2):CD000521.
doi: 10.1002/14651858.CD000521.pub3.

Anaesthesia for hip fracture surgery in adults

Joanne Guay  1 , Martyn J Parker, Pushpaj R Gajendragadkar, Sandra Kopp
Affiliations
Meta-Analysis

Anaesthesia for hip fracture surgery in adults

Joanne Guay et al. Cochrane Database Syst Rev. .

Abstract

Background: The majority of people with hip fracture are treated surgically, requiring anaesthesia.

Objectives: The main focus of this review is the comparison of regional versus general anaesthesia for hip (proximal femoral) fracture repair in adults. We did not consider supplementary regional blocks in this review as they have been studied in another review.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library; 2014, Issue 3), MEDLINE (Ovid SP, 2003 to March 2014) and EMBASE (Ovid SP, 2003 to March 2014).

Selection criteria: We included randomized trials comparing different methods of anaesthesia for hip fracture surgery in adults. The primary focus of this review was the comparison of regional anaesthesia versus general anaesthesia. The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review. The main outcomes were mortality, pneumonia, myocardial infarction, cerebrovascular accident, acute confusional state, deep vein thrombosis and return of patient to their own home.

Data collection and analysis: Two reviewers independently assessed trial quality and extracted data. We analysed data with fixed-effect (I(2) < 25%) or random-effects models. We assessed the quality of the evidence according to the criteria developed by the GRADE working group.

Main results: In total, we included 31 studies (with 3231 participants) in our review. Of those 31 studies, 28 (2976 participants) provided data for the meta-analyses. For the 28 studies, 24 were used for the comparison of neuraxial block versus general anaesthesia. Based on 11 studies that included 2152 participants, we did not find a difference between the two anaesthetic techniques for mortality at one month: risk ratio (RR) 0.78, 95% confidence interval (CI) 0.57 to 1.06; I(2) = 24% (fixed-effect model). Based on six studies that included 761 participants, we did not find a difference in the risk of pneumonia: RR 0.77, 95% CI 0.45 to 1.31; I(2) = 0%. Based on four studies that included 559 participants, we did not find a difference in the risk of myocardial infarction: RR 0.89, 95% CI 0.22 to 3.65; I(2) = 0%. Based on six studies that included 729 participants, we did not find a difference in the risk of cerebrovascular accident: RR 1.48, 95% CI 0.46 to 4.83; I(2) = 0%. Based on six studies that included 624 participants, we did not find a difference in the risk of acute confusional state: RR 0.85, 95% CI 0.51 to 1.40; I(2) = 49%. Based on laboratory tests, the risk of deep vein thrombosis was decreased when no specific precautions or just early mobilization was used: RR 0.57, 95% CI 0.41 to 0.78; I(2) = 0%; (number needed to treat for an additional beneficial outcome (NNTB) = 3, 95% CI 2 to 7, based on a basal risk of 76%) but not when low molecular weight heparin was administered: RR 0.98, 95% CI 0.52 to 1.84; I(2) for heterogeneity between the two subgroups = 58%. For neuraxial blocks compared to general anaesthesia, we rated the quality of evidence as very low for mortality (at 0 to 30 days), pneumonia, myocardial infarction, cerebrovascular accident, acute confusional state, decreased rate of deep venous thrombosis in the absence of potent thromboprophylaxis, and return of patient to their own home. The number of studies comparing other anaesthetic techniques was limited.

Authors' conclusions: We did not find a difference between the two techniques, except for deep venous thrombosis in the absence of potent thromboprophylaxis. The studies included a wide variety of clinical practices. The number of participants included in the review is insufficient to eliminate a difference between the two techniques in the majority of outcomes studied. Therefore, large randomized trials reflecting actual clinical practice are required before drawing final conclusions.

PubMed Disclaimer

Conflict of interest statement

Joanne Guay: I am the editor of a multi authors textbook on anaesthesia (including notions on general and regional anaesthesia).

Martyn J Parker has received expenses and honorarium from a number of commercial companies and organizations for giving lectures on different aspects of hip fracture treatment. In addition he has received royalties from BBraun ltd related to the design and development of an implant used for the internal fixation of intracapsular hip fractures. This implant and fracture type is not considered in this review and none of these payments related directly to this review. He is the author of one ongoing trial (ISRCTN36381516).

Pushpaj R Gajendragadkar: none known.

Sandra Kopp: none known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Meta‐regression of mortality at 0‐1 month versus the year when the study was published. The effect size decreases with time: P value = 0.002. This meta regression plot was not produced in RevMan. The figure was generated automatically by the software, and cannot be amended. The software has expressed the years as decimals.
1.1
1.1. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 1 Mortality ‐ 1 month.
1.2
1.2. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 2 Mortality ‐ 3 months.
1.3
1.3. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 3 Mortality ‐ 6 months.
1.4
1.4. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 4 Mortality ‐ 12 months.
1.5
1.5. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 5 Pneumonia.
1.6
1.6. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 6 Myocardial infarction.
1.7
1.7. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 7 Cerebrovascular accident.
1.8
1.8. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 8 Acute confusional state.
1.9
1.9. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 9 Deep vein thrombosis.
1.10
1.10. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 10 Congestive cardiac failure.
1.11
1.11. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 11 Acute kidney injury.
1.12
1.12. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 12 Pulmonary embolism.
1.13
1.13. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 13 Number of patients transfused.
1.14
1.14. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 14 Length of hospital stay.
1.15
1.15. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 15 Length of surgery (minutes).
1.16
1.16. Analysis
Comparison 1 Neuraxial block (spinal or epidural) versus general anaesthesia, Outcome 16 Operative hypotension.
2.1
2.1. Analysis
Comparison 2 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 1 Incomplete or unsatisfactory analgesia.
2.2
2.2. Analysis
Comparison 2 Regional (spinal or epidural) versus lumbar plexus nerve blocks, Outcome 2 Urine retention.
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References

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References to other published versions of this review

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