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

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Anthony Rodgers, codirector (a.rodgers{at}ctru.auckland.ac.nz)a,
Natalie Walker, research fellowa,
S Schug, professorb,
A McKee, consultant anaesthetistc,
H Kehlet, professord,
A van Zundert, consultant anaesthetiste,
D Sage, consultant anaesthetistf,
M Futter, consultant anaesthetistf,
G Saville, consultant anaesthetistg,
T Clark, statisticiana,
S MacMahon, professorh

^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

Accepted 4 September 2000

Abstract

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.

Footnotes

Funding Health Research Council of New Zealand and Astra Pain, New Zealand. NW undertook this research during the tenure of a training fellowship from the Health Research Council of New Zealand. AR is a senior research fellow of the National Heart Foundation of New Zealand.
Competing interests HK has received fees for consulting and speaking at meetings from AstraZeneca.