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Anthony Rodgers a Clinical Trials Research Unit, Department of
Medicine, University of Auckland, Private Bag 92019, Auckland, New
Zealand, b Division of Anaesthesiology, University of Auckland, c Department of Anaesthetics, Green
Lane Hospital, Epsom, Auckland 1003, New Zealand, d Department of
Surgical Gastroenterology, Hvidovre University Hospital, DK-2650
Hvidovre, Denmark, e Department of Anesthesiology, Intensive Care and Pain Therapy,
Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, Netherlands, f Department of Anaesthesia,
Auckland and Starship Hospitals, Private Bag 92024, Auckland, New
Zealand, g Department of
Anaesthesia, Royal Cornwall Hospital, Treliske, Truro TR1 3LJ, h Institute
for International Health, University of Sydney, PO Box 1225, Crows
Nest, Sydney, NSW 1585, Australia
Correspondence to: A Rodgers
a.rodgers{at}ctru.auckland.ac.nz
Objectives:
To obtain reliable estimates of the
effects of neuraxial blockade with epidural or spinal anaesthesia on
postoperative morbidity and mortality.
Design:
Systematic review of all trials with
randomisation to intraoperative neuraxial blockade or not.
Studies:
141 trials including 9559 patients for which data were available before 1 January 1997. Trials were eligible irrespective of their primary aims, concomitant use of general anaesthesia, publication status, or language. Trials were identified by
extensive search methods, and substantial amounts of data were obtained
or confirmed by correspondence with trialists.
Main outcome measures:
All cause mortality, deep
vein thrombosis, pulmonary embolism, myocardial infarction, transfusion
requirements, pneumonia, other infections, respiratory depression, and
renal failure.
Results:
Overall mortality was reduced by about a
third in patients allocated to neuraxial blockade (103 deaths/4871
patients versus 144/4688 patients, odds ratio=0.70, 95% confidence
interval 0.54 to 0.90, P=0.006). Neuraxial blockade reduced the odds of deep vein thrombosis by 44%, pulmonary embolism by 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by
59% (all P<0.001). There were also reductions in myocardial infarction and renal failure. Although there was limited power to
assess subgroup effects, the proportional reductions in mortality did
not clearly differ by surgical group, type of blockade (epidural or
spinal), or in those trials in which neuraxial blockade was combined
with general anaesthesia compared with trials in which neuraxial
blockade was used alone.
Conclusions:
Neuraxial blockade reduces postoperative
mortality and other serious complications. The size of some of these
benefits remains uncertain, and further research is required to
determine whether these effects are due solely to benefits of neuraxial blockade or partly to avoidance of general anaesthesia. Nevertheless, these findings support more widespread use of neuraxial blockade.
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