Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised

doi:10.1136/bmj.321.7275.1493

BMJ 2000;321:1493 ( 16 December )

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Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials

Anthony Rodgers, codirector, ^a Natalie Walker, research fellow, ^a S Schug, professor, ^b A McKee, consultant anaesthetist, ^c H Kehlet, professor, ^d A van Zundert, consultant anaesthetist, ^e D Sage, consultant anaesthetist, ^f M Futter, consultant anaesthetist, ^f G Saville, consultant anaesthetist, ^g T Clark, statistician, ^a S MacMahon, professor. ^h

^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 effectsof neuraxial blockade with epidural or spinal anaesthesia on postoperativemorbidity andmortality.
Design: Systematic review of all trials with randomisationto intraoperative neuraxial blockade ornot.
Studies: 141 trials including 9559 patients for whichdata were available before 1 January 1997. Trials were eligibleirrespective of their primary aims, concomitant use of generalanaesthesia, publication status, or language. Trials were identifiedby extensive search methods, and substantial amounts of data wereobtained or confirmed by correspondence withtrialists.
Main outcome measures: All cause mortality, deep vein thrombosis,pulmonary embolism, myocardial infarction, transfusion requirements,pneumonia, other infections, respiratory depression, and renalfailure.
Results: Overall mortality was reduced by about a thirdin patients allocated to neuraxial blockade (103 deaths/4871 patientsversus 144/4688 patients, odds ratio=0.70, 95% confidence interval0.54 to 0.90, P=0.006). Neuraxial blockade reduced the odds ofdeep vein thrombosis by 44%, pulmonary embolism by 55%, transfusionrequirements by 50%, pneumonia by 39%, and respiratory depressionby 59% (all P<0.001). There were also reductions in myocardialinfarction and renal failure. Although there was limited powerto assess subgroup effects, the proportional reductions in mortalitydid not clearly differ by surgical group, type of blockade (epiduralor spinal), or in those trials in which neuraxial blockade wascombined with general anaesthesia compared with trials in whichneuraxial blockade was usedalone.
Conclusions: Neuraxial blockade reduces postoperative mortalityand other serious complications. The size of some of these benefitsremains uncertain, and further research is required to determinewhether these effects are due solely to benefits of neuraxialblockade or partly to avoidance of general anaesthesia. Nevertheless,these findings support more widespread use of neuraxialblockade.

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bmj.com, 19 Dec 2000 [Full text]
Outcome benefits from epidural anaesthesia: true for all surgical groups?: R Jonathan T Wilson
bmj.com, 20 Dec 2000 [Full text]
Odds ratios are best displayed on a logarithmic scale: Sally Hollis
bmj.com, 10 Jan 2001 [Full text]
Accurate summary or misleading statement?: Andrew Norris
bmj.com, 12 Jan 2001 [Full text]
Re: Control for confounding factors: Johann Harten
bmj.com, 12 Jan 2001 [Full text]
Number needed to treat derived from a meta-analysis may be misleading: Markku Hynynen
bmj.com, 18 Jan 2001 [Full text]
Comparing Apples with Fruit Salad?: Timothy James McCulloch
bmj.com, 19 Jan 2001 [Full text]
Regional or general anaesthesia: is the question answered?: Helen Higham
bmj.com, 19 Jan 2001 [Full text]
Comment to Rodgers et al, BMJ 2000;321:1493: K D Stuhmeier
bmj.com, 14 Feb 2001 [Full text]