Method of Anesthesia and Perioperative Risk Factors, Maternal Anesthesia Complications, and Neonatal Mortality Following Cesarean Delivery in Africa: A Substudy of a 7-Day Prospective Observational Cohort Study.

BACKGROUND: The African Surgical Outcomes Study (ASOS) found that maternal mortality following cesarean delivery in Africa is 50 times higher than in high-income countries, and associated with obstetric hemorrhage and anesthesia complications. Mothers who died were more likely to receive general anesthesia (GA). The associations between GA versus spinal anesthesia (SA) and preoperative risk factors, maternal anesthesia complications, and neonatal outcomes following cesarean delivery in Africa are unknown. METHODS: This is a secondary explanatory analysis of 3792 patients undergoing cesarean delivery in ASOS, a prospective observational cohort study, across 22 African countries. The primary aim was to estimate the association between preoperative risk factors and the outcome of the method of anesthesia delivered. Secondary aims were to estimate the association between the method of anesthesia and the outcomes (1) maternal intraoperative hypotension, (2) severe maternal anesthesia complications, and (3) neonatal mortality. Generalized linear mixed models adjusting for obstetric gravidity and gestation, American Society of Anesthesiologists (ASA) category, urgency of surgery, maternal comorbidities, fetal distress, and level of anesthesia provider were used. RESULTS: Of 3709 patients, SA was performed in 2968 (80%) and GA in 741 (20%). Preoperative factors independently associated with GA for cesarean delivery were gestational age (adjusted odds ratio [aOR], 1.093; 95% confidence interval [CI], 1.052-1.135), ASA categories III (aOR, 11.84; 95% CI, 2.93-46.31) and IV (aOR, 11.48; 95% CI, 2.93-44.93), eclampsia (aOR, 3.92; 95% CI, 2.18-7.06), placental abruption (aOR, 6.23; 95% CI, 3.36-11.54), and ruptured uterus (aOR, 3.61; 95% CI, 1.36-9.63). SA was administered to 48 of 94 (51.1%) patients with eclampsia, 12 of 28 (42.9%) with cardiac disease, 14 of 19 (73.7%) with preoperative sepsis, 48 of 76 (63.2%) with antepartum hemorrhage, 30 of 55 (54.5%) with placenta previa, 33 of 78 (42.3%) with placental abruption, and 12 of 29 (41.4%) with a ruptured uterus. The composite maternal outcome "all anesthesia complications" was more frequent in GA than SA (9/741 [1.2%] vs 3/2968 [0.1%], P < .001). The unadjusted neonatal mortality was higher with GA than SA (65/662 [9.8%] vs 73/2669 [2.7%], P < .001). The adjusted analyses demonstrated no association between method of anesthesia and (1) intraoperative maternal hypotension and (2) neonatal mortality. CONCLUSIONS: Analysis of patients undergoing anesthesia for cesarean delivery in Africa indicated patients more likely to receive GA. Anesthesia complications and neonatal mortality were more frequent following GA. SA was often administered to high-risk patients, including those with eclampsia or obstetric hemorrhage. Training in the principles of selection of method of anesthesia, and the skills of safe GA and neonatal resuscitation, is recommended.

Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis.

BACKGROUND: Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes. METHODS: The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations. RESULTS: The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87. CONCLUSIONS: Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation. RECOMMENDATION: neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty. TRIAL REGISTRY NUMBER: PROSPERO CRD42018099935.

Endovascular Abdominal Aortic Aneurysm Repair: Does Anesthesia Type Matter?

BACKGROUND: Given the various types of anesthesia used for endovascular abdominal aortic aneurysm repair (EVAR), we sought to determine the effect of anesthesia type in the outcomes of elective EVAR in a large multiinstitutional healthcare maintenance organization. METHODS: A retrospective chart review was conducted on all elective EVAR conducted from August 2010 to August 2017 in 14 regional hospitals of Kaiser Permanente Southern California. Patients undergoing emergent, nonelective abdominal aortic aneurysm repairs, thoracoabdominal aneurysm repair, requiring conversion to open surgery or general anesthesia were excluded from the study. Basic demographic information, medical risk factors, anesthesia type, operative data, and postoperative morbidity and mortality data were obtained for univariate and multivariate statistical analysis. RESULTS: A total of 1,536 patients underwent EVAR, of which 1,206 met inclusion criteria. A total of 788 patients underwent general anesthesia, 164 patients underwent spinal anesthesia, 82 patients underwent epidural anesthesia, and 172 patients underwent local and monitored anesthesia care (AC). There was a significant difference in length of stay and operative time when comparing local/monitored AC to general anesthesia. No significant difference was noted in 30-day morbidity or mortality among the anesthesia groups. CONCLUSIONS: Local and regional anesthesia is a safe and effective approach for elective EVAR.

General versus spinal anaesthesia in proximal femoral fracture surgery - treatment outcomes.

BACKGROUND: Proximal femoral fractures are a major public health problem because of the increasing proportion of elderly individuals in the general population. The mode of choice for anaesthesia in surgical treatment of these fractures is still debated in terms of better postoperative outcome. The aim of our study was to compare the effect of general over spinal anaesthesia on mortality in proximal femoral fracture surgery. PATIENTS AND METHODS: This study was a retrospective analysis of 115 patients aged at least 70 years who underwent surgery for proximal femoral fracture. The survey was conducted from 1 January to 31 December 2015 at the General Hospital Karlovac, Croatia. Patients were divided into two groups: group 1 - general anaesthesia and group 2 - spinal anaesthesia. The primary outcome measure was the effect of mode of anaesthesia, general versus spinal, on mortality within 30 days, six months and one year after surgery. RESULTS: General anaesthesia (EndoTracheal Anaesthesia) was administered in 77 patients (67%; group I - ETA) and spinal anaesthesia in 38 patients (33%; group 2 - SPIN). Both groups had more female than male patients: 69 patients (89.6%) in the ETA group and 32 patients (84.2%) in the SPIN group were female. The mean age in the ETA group was 82.91 years and in the SPIN group was 80.18 years. ASA II status was more common in patients in the SPIN group (25 patients [65.8%]). The average time from hospitalisation to surgery was 53.44 hours in the ETA group and 53.33 hours in the SPIN group. There was no significant difference between groups in the number of comorbidities, or intraoperative and postoperative complications. There was no statistically significant difference in mortality between the groups. Mortality after surgery in the ETA and SPIN groups, respectively, was as follows: 10.4% and 10.5% at 30 days, 23.4% and 15.8% at six months, and 32.5% and 31.6% at one year. CONCLUSION: The results indicate that the mode of anaesthesia (general vs spinal) has no effect on postoperative mortality, and that the mode of anaesthesia should be applied on an individual basis in correlation with associated comorbidities.

Neuraxial and Combined Neuraxial/General Anesthesia Compared to General Anesthesia for Major Truncal and Lower Limb Surgery: A Systematic Review and Meta-analysis.

Neuraxial anesthesia may improve perioperative outcomes when compared to general anesthesia; however, this is controversial. We performed a systematic review and meta-analysis using randomized controlled trials and population-based observational studies identified in MEDLINE, PubMed, and EMBASE from 2010 to May 31, 2016. Studies were included for adult patients undergoing major surgery of the trunk and lower extremity that reported: 30-day mortality (primary outcome), cardiopulmonary morbidity, surgical site infection, thromboembolic events, blood transfusion, and resource use. Perioperative outcomes were compared with general anesthesia for the following subgroups: combined neuraxial-general anesthesia and neuraxial anesthesia alone. Odds ratios (ORs) and 99% confidence intervals (CIs) were calculated to identify the impact of anesthetic technique on outcomes. Twenty-seven observational studies and 11 randomized control trials were identified. This analysis comprises 1,082,965 records from observational studies or databases and 1134 patients from randomized controlled trials. There was no difference in 30-day mortality identified when combined neuraxial-general anesthesia was compared with general anesthesia (OR 0.88; 99% CI, 0.77-1.01), or when neuraxial anesthesia was compared with general anesthesia (OR 0.98; 99% CI, 0.92-1.04). When combined neuraxial-general anesthesia was compared with general anesthesia, combined neuraxial-general anesthesia was associated with a reduced odds of pulmonary complication (OR 0.84; 99% CI, 0.79-0.88), surgical site infection (OR 0.93; 99% CI, 0.88-0.98), blood transfusion (OR 0.90; 99% CI, 0.87-0.93), thromboembolic events (OR 0.84; 99% CI, 0.73-0.98), length of stay (mean difference -0.16 days; 99% CI, -0.17 to -0.15), and intensive care unit admission (OR 0.77; 99% CI, 0.73-0.81). For the combined neuraxial-general anesthesia subgroup, there were increased odds of myocardial infarction (OR 1.18; 99% CI, 1.01-1.37). There was no difference identified in the odds of pneumonia (OR 0.94; 99% CI, 0.87-1.02) or cardiac complications (OR 1.04; 99% CI, 1.00-1.09) for the combined neuraxial-general anesthesia subgroup. When neuraxial anesthesia was compared to general anesthesia, there was a decreased odds of any pulmonary complication (OR 0.38; 99% CI, 0.36-0.40), surgical site infection (OR 0.76; 99% CI, 0.71-0.82), blood transfusion (OR 0.85; 99% CI, 0.82-0.88), thromboembolic events (OR 0.79; 99% CI, 0.68-0.91), length of stay (mean difference -0.29 days; 99% CI, -0.29 to -0.28), and intensive care unit admission (OR 0.50; 99% CI, 0.48-0.53). There was no difference in the odds of cardiac complications (OR 0.99; 99% CI, 0.94-1.03), myocardial infarction (OR 0.91; 99% CI, 0.81-1.02), or pneumonia (OR 0.92; 99% CI, 0.84-1.01). Randomized control trials revealed no difference in requirement for blood transfusion (RR 1.05; 99% CI, 0.65-1.71) and a decreased length of stay (mean difference -0.15 days; 99% CI, -0.27 to -0.04). Neuraxial anesthesia when combined with general anesthesia or when used alone was not associated with decreased 30-day mortality. Neuraxial anesthesia may improve pulmonary outcomes and reduce resource use when compared with general anesthesia. However, because observational studies were included in this analysis, there is a risk of residual confounding and therefore these results should be interpreted with caution.

Anesthesia Technique and Mortality after Total Hip or Knee Arthroplasty: A Retrospective, Propensity Score-matched Cohort Study.

BACKGROUND: This propensity score-matched cohort study evaluates the effect of anesthetic technique on a 30-day mortality after total hip or knee arthroplasty. METHODS: All patients who had hip or knee arthroplasty between January 1, 2003, and December 31, 2014, were evaluated. The principal exposure was spinal versus general anesthesia. The primary outcome was 30-day mortality. Secondary outcomes were (1) perioperative myocardial infarction; (2) a composite of major adverse cardiac events that includes cardiac arrest, myocardial infarction, or newly diagnosed arrhythmia; (3) pulmonary embolism; (4) major blood loss; (5) hospital length of stay; and (6) operating room procedure time. A propensity score-matched-pair analysis was performed using a nonparsimonious logistic regression model of regional anesthetic use. RESULTS: We identified 10,868 patients, of whom 8,553 had spinal anesthesia and 2,315 had general anesthesia. Ninety-two percent (n = 2,135) of the patients who had general anesthesia were matched to similar patients who did not have general anesthesia. In the matched cohort, the 30-day mortality rate was 0.19% (n = 4) in the spinal anesthesia group and 0.8% (n = 17) in the general anesthesia group (risk ratio, 0.42; 95% CI, 0.21 to 0.83; P = 0.0045). Spinal anesthesia was also associated with a shorter hospital length of stay (5.7 vs. 6.6 days; P < 0.001). CONCLUSIONS: The results of this observational, propensity score-matched cohort study suggest a strong association between spinal anesthesia and lower 30-day mortality, as well as a shorter hospital length of stay, after elective joint replacement surgery.

Similar mortality with general or regional anesthesia in elderly hip fracture patients.

BACKGROUND AND PURPOSE: There is continuing confusion among practitioners with regard to the optimal choice of anesthetic type for repair of hip fractures. We investigated whether type of anesthetic was associated with short-term mortality after hip fracture surgery. PATIENTS AND METHODS: We conducted a retrospective cohort study of patients with surgically treated hip fractures, performed between January 1, 2009 and December 31, 2012. Exposure of interest was anesthesia type (general, spinal/neuroaxial, and mixed). Endpoints were 30-, 90-, and 365-day post-surgery mortality. Multivariable conditional logistic regression models were used and odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS: Of the 7,585 participants, 5,412 (71%) were women and the median age was 80 (IQR: 72-85) years old. Of the total cohort, 4,257 (56%) received general anesthesia, 3,059 (40%) received spinal/neuroaxial, and 269 (4%) received mixed anesthesia. Overall, the incidence of 30-, 90-, and 365-day mortality was 4% (n = 307), 8% (n = 583), and 15% (n = 1,126), respectively. When compared with general anesthesia, the 365-day odds of mortality was marginally lower in patients with spinal/neuroaxial anesthesia (OR = 0.84, CI: 0.70-1.0), but it was similar in patients with mixed anesthesia (OR = 1.3, CI: 0.70-2.3). No other statistically significant differences were observed. INTERPRETATION: Regarding mortality, this study does not support specific recommendations regarding the type of anesthetic in surgery of fractured hips.

Neuraxial anesthesia for orthopedic surgery: systematic review and meta-analysis of randomized clinical trials.

CONTEXT AND OBJECTIVE: Taking the outcome of mortality into consideration, there is controversy about the beneficial effects of neuraxial anesthesia for orthopedic surgery. The aim of this study was to compare the effectiveness and safety of neuraxial anesthesia versus general anesthesia for orthopedic surgery. DESIGN AND SETTING: Systematic review at Universidade Federal de Alagoas. METHODS: We searched the Cochrane Central Register of Controlled Trials (Issue 10, 2012), PubMed (1966 to November 2012), Lilacs (1982 to November 2012), SciELO, EMBASE (1974 to November 2012) and reference lists of the studies included. Only randomized controlled trials were included. RESULTS: Out of 5,032 titles and abstracts, 17 studies were included. There were no statistically significant differences in mortality (risk difference, RD: -0.01; 95% confidence interval, CI: -0.04 to 0.01; n = 1903), stroke (RD: 0.02; 95% CI: -0.04 to 0.08; n = 259), myocardial infarction (RD: -0.01; 95% CI: -0.04 to 0.02; n = 291), length of hospitalization (mean difference, -0.05; 95% CI: -0.69 to 0.58; n = 870), postoperative cognitive dysfunction (RD: 0.00; 95% CI: -0.04 to 0.05; n = 479) or pneumonia (odds ratio, 0.61; 95% CI: 0.25 to 1.49; n = 167). CONCLUSION: So far, the evidence available from the studies included is insufficient to prove that neuraxial anesthesia is more effective and safer than general anesthesia for orthopedic surgery. However, this systematic review does not rule out clinically important differences with regard to mortality, stroke, myocardial infarction, length of hospitalization, postoperative cognitive dysfunction or pneumonia.

Neuraxial anaesthesia for lower-limb revascularization.

BACKGROUND: Lower-limb revascularization is a surgical procedure that is performed to restore an adequate blood supply to the limbs. Lower-limb revascularization surgery is used to reduce pain and sometimes to improve lower-limb function. Neuraxial anaesthesia is an anaesthetic technique that uses local anaesthetics next to the spinal cord to block nerve function. Neuraxial anaesthesia may lead to improved survival. This systematic review was originally published in 2010 and was first updated in 2011 and again in 2013. OBJECTIVES: To determine the rates of death and major complications associated with spinal and epidural anaesthesia as compared with other types of anaesthesia for lower-limb revascularization in patients aged 18 years or older who are affected by obstruction of lower-limb vessels. SEARCH METHODS: The original review was published in 2010 and was based on a search until June 2008. In 2011 we reran the search until February 2011 and updated the review. For this second updated version of the review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, CINAHL and Web of Science from 2011 to April 2013. SELECTION CRITERIA: We included randomized controlled trials comparing neuraxial anaesthesia (spinal or epidural anaesthesia) versus other types of anaesthesia in adults (18 years or older) with arterial vascular obstruction undergoing lower-limb revascularization surgery. DATA COLLECTION AND ANALYSIS: Two review authors independently performed data extraction and assessed trial quality. We pooled the data on mortality, myocardial infarction, lower-limb amputation and pneumonia. We summarized dichotomous data as odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. MAIN RESULTS: In this updated version of the review, we found no new studies that met our inclusion criteria. We included in this review four studies that compared neuraxial anaesthesia with general anaesthesia. The total number of participants was 696, of whom 417 were allocated to neuraxial anaesthesia and 279 to general anaesthesia. Participants allocated to neuraxial anaesthesia had a mean age of 67 years, and 59% were men. Participants allocated to general anaesthesia had a mean age of 67 years, and 66% were men. Four studies had an unclear risk of bias. No difference was observed between participants allocated to neuraxial or general anaesthesia in mortality rate (OR 0.89, 95% CI 0.38 to 2.07; 696 participants; four trials), myocardial infarction (OR 1.23, 95% CI 0.56 to 2.70; 696 participants; four trials), and lower-limb amputation (OR 0.84, 95% CI 0.38 to 1.84; 465 participants; three trials). Pneumonia was less common after neuraxial anaesthesia than after general anaesthesia (OR 0.37, 95% CI 0.15 to 0.89; 201 participants; two trials). Evidence was insufficient for cerebral stroke, duration of hospital stay, postoperative cognitive dysfunction, complications in the anaesthetic recovery room and transfusion requirements. No data described nerve dysfunction, postoperative wound infection, patient satisfaction, postoperative pain score, claudication distance and pain at rest. AUTHORS' CONCLUSIONS: Available evidence from included trials that compared neuraxial anaesthesia with general anaesthesia was insufficient to rule out clinically important differences for most clinical outcomes. Neuraxial anaesthesia may reduce pneumonia. No conclusions can be drawn with regard to mortality, myocardial infarction and rate of lower-limb amputation, or less common outcomes.

Neuraxial anesthesia for orthopedic surgery: systematic review and meta-analysis of randomized clinical trials / Anestesia neuroaxial para cirurgia ortopedica: revisao sistematica e metanalise de ensaios clinicos randomizados

CONTEXT AND OBJECTIVE: Taking the outcome of mortality into consideration, there is controversy about the beneficial effects of neuraxial anesthesia for orthopedic surgery. The aim of this study was to compare the effectiveness and safety of neuraxial anesthesia versus general anesthesia for orthopedic surgery. DESIGN AND SETTING: Systematic review at Universidade Federal de Alagoas. METHODS: We searched the Cochrane Central Register of Controlled Trials (Issue 10, 2012), PubMed (1966 to November 2012), Lilacs (1982 to November 2012), SciELO, EMBASE (1974 to November 2012) and reference lists of the studies included. Only randomized controlled trials were included. RESULTS: Out of 5,032 titles and abstracts, 17 studies were included. There were no statistically significant differences in mortality (risk difference, RD: -0.01; 95% confidence interval, CI: -0.04 to 0.01; n = 1903), stroke (RD: 0.02; 95% CI: -0.04 to 0.08; n = 259), myocardial infarction (RD: -0.01; 95% CI: -0.04 to 0.02; n = 291), length of hospitalization (mean difference, -0.05; 95% CI: -0.69 to 0.58; n = 870), postoperative cognitive dysfunction (RD: 0.00; 95% CI: -0.04 to 0.05; n = 479) or pneumonia (odds ratio, 0.61; 95% CI: 0.25 to 1.49; n = 167). CONCLUSION: So far, the evidence available from the studies included is insufficient to prove that neuraxial anesthesia is more effective and safer than general anesthesia for orthopedic surgery. However, this systematic review does not rule out clinically important differences with regard to mortality, stroke, myocardial infarction, length of hospitalization, postoperative cognitive dysfunction or pneumonia. .

CONTEXTO E OBJETIVO: Considerando o desfecho de mortalidade, existe controvérsia acerca dos efeitos benéficos da anestesia neuroaxial (AN) para cirurgias ortopédicas. O objetivo do estudo foi comparar efetividade e segurança da AN versus anestesia geral (AG) para cirurgias ortopédicas. TIPO DE ESTUDO E LOCAL: Revisão sistemática na Universidade Federal de Alagoas. MÉTODOS: Buscamos em Cochrane Central Register of Controlled Trials (2012, volume 10), PubMed (1966 até novembro de 2012), Lilacs (1982 até novembro de 2012), SciELO, EMBASE (1974 até novembro de 2012) e listas de referências dos estudos incluídos. Apenas ensaios clínicos randomizados foram incluídos. RESULTADOS: Dentre 5.032 títulos e resumos, 17 estudos foram incluídos. Não houve diferença estatística em mortalidade (diferença de risco, DR: -0,01; intervalo de confiança de 95%, IC: -0,04 a 0.01; n = 1903), em acidente vascular encefálico (DR: 0,02; IC 95%: -0,04 a 0,08; n = 259, em infarto miocárdico (DR: -0.01; IC 95%: -0,04 a 0.02; n = 291), tempo de hospitalização (diferença média, -0,05; IC 95%: -0,69 a 0,58; n = 870), em disfunção cognitiva pós-operatória (DR: 0,00; IC 95%: -0,04 a 0,05; n = 479) e pneumonia (razão de chances, 0,61; IC 95%: 0,25 a 1,49; n = 167). CONCLUSÃO: Até o momento, as evidências são insuficientes nos estudos incluídos para provar que AN é mais efetiva e segura do que AG para cirurgias ortopédicas. Esta revisão sistemática não descartou diferenças clínicas importantes para mortalidade, acidente vascular encefálico, infarto miocárdico, tempo de internação, disfunção cognitiva pós-operatória e pneumonia. .

Brief reports: paravertebral block for anesthesia: a systematic review.

BACKGROUND: The objective of this review was to assess the safety and efficacy of thoracic and lumbar paravertebral blocks (PVBs) for surgical anesthesia through a systematic review of the peer-reviewed literature. PVBs for surgical anesthesia were compared with general anesthesia (GA) or other regional anesthetic techniques. METHODS: We searched literature databases including MEDLINE, EMBASE, and The Cochrane Library up to May 2008. Included studies were limited to eligible randomized controlled trials. Eight randomized controlled trials were included in this review, 6 of which used PVBs for anesthesia during breast surgery, and 2 trials used PVB for anesthesia during herniorrhaphy. RESULTS: The ability to obtain firm conclusions was limited by the diversity of outcomes and how they were measured, which varied across studies. The PVB failure rate was not >13%, and patients were more satisfied with PVB than with GA. There was some indication that PVB could achieve shorter hospital stays than GA. PVB for anesthesia substantially reduces nausea and vomiting in comparison with GA (relative risk: 0.25, 95% CI: 0.13-0.50; P < 0.05), although it does carry a risk of pleural puncture and epidural spread of local anesthetic. CONCLUSIONS: In conclusion, based on the current evidence, PVBs for surgical anesthesia at the level of the thoracic and lumbar vertebrae are associated with less pain during the immediate postoperative period, as well as less postoperative nausea and vomiting, and greater patient satisfaction compared with GA.

Neuraxial anaesthesia for lower-limb revascularization.

BACKGROUND: Lower-limb revascularization surgery is used to reduce pain and sometimes to improve lower-limb function. The type of anaesthesia used during lower-limb revascularization may affect the risks of both good and bad outcomes. OBJECTIVES: To determine the rates of death and major complications with spinal and epidural anaesthesia compared with other types of anaesthesia for lower-limb revascularization. SEARCH STRATEGY: We searched CENTRAL (The Cochrane Library 2008, Issue 2); MEDLINE (1960 to 10th June 2008); EMBASE (1982 to 10th June 2008); LILACS (1982 to 10th June 2008); CINAHL (1982 to 10th June 2008) and ISI Web of Science (1900 to 10th June 2008). SELECTION CRITERIA: We included randomized controlled trials that evaluated the effect of anaesthetic type in adults aged 18 years or older undergoing lower-limb revascularization surgery. DATA COLLECTION AND ANALYSIS: Two authors independently performed the data extraction. Primary outcomes were mortality, cerebral stroke, myocardial infarction, nerve dysfunction and postoperative lower-limb amputation rate. The secondary outcome analysed was pneumonia. We judged risk of bias with four criteria: randomization and allocation concealment methods, blinding of treatment and outcome assessment and completeness of follow up. To assess heterogeneity we used the I(2) statistic. We summarized dichotomous data as odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. MAIN RESULTS: We included four studies that compared neuraxial anaesthesia with general anaesthesia. The total number of participants was 696, of whom 417 were allocated to neuraxial anaesthesia and 279 to general anaesthesia. Participants allocated to neuraxial anaesthesia had a mean age of 67 years and 59% were men. Participants allocated to general anaesthesia had a mean age of 67 years and 66% were men. There was no difference between participants allocated to neuraxial or general anaesthesia in: mortality rate (OR 0.89, 95% CI 0.38 to 2.07; 696 participants, four trials); myocardial infarction (OR 1.23, 95% CI 0.56 to 2.70; 696 participants, four trials); and lower-limb amputation rate (OR 0.84, 95% CI 0.38 to 1.84; 465 participants, three trials). Pneumonia was less common following neuraxial anaesthesia than general anaesthesia (OR 0.37, 95% CI 0.15 to 0.89; 201 participants, two trials). AUTHORS' CONCLUSIONS: There was insufficient evidence available from the included trials that compared neuraxial anaesthesia with general anaesthesia to rule out clinically important differences for most clinical outcomes. Neuraxial anaesthesia may reduce pneumonia. No conclusions can be drawn with regard to mortality, myocardial infarction and rate of lower-limb amputation or less common outcomes.

Deaths associated with anaesthesia in Togo, West Africa.

This study attempts to determine the anaesthetic death rate, the causes of deaths and the avoidable mortality rate (AMR) in consecutive cases. The number of anaesthetics given was 1464: 30 cases died within 24 h. The incidence of 24-h perioperative deaths per 100 anaesthetics was 2.57. In all, 50% of deaths were observed in obstetric surgery; 47% of deaths were associated with cardiovascular management, 30% with respiratory management; 93% of deaths were identified as avoidable. The AMR was 1.5% (anaesthetic AMR: 0.75%, administrative AMR: 0.68%, surgical AMR: 0.07%). Insufficient or no blood available is the only factor for administrative AMR.

[Practice and complications of spinal anesthesia in African tropical countries]. / Pratique et complications de la rachianesthésie en milieu tropical africain.

OBJECTIVE: To evaluate the risk of the practice of spinal anaesthesia (SA) in African tropics. STUDY DESIGN: Prospective study in multiple centres over a two years period. PERSONS: Twenty-one anaesthesiologists and anaesthetist nurses covering ten African countries. METHODS: Two anonymous questionnaires; the first, filled in each anaesthetic problem occurred, to define the type of incident or accident, and its circumstances; the second was designed to define the position occupied, to quantify the global anaesthetic activity, the number of SA, and to value the number of complications or deaths linked to SA. RESULTS: Six anaesthesiologists and one anaesthetist nurse replied to the study, covering six sites in five different countries (Senegal, Chad, Central African Republic, Niger and Madagascar). On the 18,432 anaesthetic acts collected, 2,703 (14.7%) were SA. In the well-equipped centres, general anaesthesia was predominant with a frequency of over 75%. However in the not so well equipped centres or those which supplies were more problematical, SA technique was used with a frequency varying from 48.9 to 68.7%. Forty incidents and accidents were reported (1.5%), five led to the death of the patient (0.2%). Among the seven cardiac arrests (0.3%), four were fatal (0.1%). Eight of the ten accidents and all of the deaths occurred in the least equipped centres. Eight of ten accidents happened during emergency caesarean sections. All cardiac arrests were preceded by a severe hypovolemia. For the four deaths after cardiac arrest, an anaesthetist nurse with isobaric bupivacaine 0.5% carried out SA. CONCLUSIONS: This study showed that the practice of SA in African tropics was performing in different practice conditions and people qualification than they were in France. The frequency of cardiac arrests and deaths was respectively five and 20 times more important, in those conditions. The first conclusion that can be drawn from this study is that it is questionable to use SA for emergency Caesarean section under hypovolemic condition. The second is the necessity for specific training on the local anaesthesia for anaesthetist nurses but also training to choose the anaesthesia best adapted to the surgery, the condition of the patient and the means available.

Blood concentrations of tetracaine and its metabolite following spinal anesthesia.

Blood concentrations of tetracaine and its metabolite, p-butylaminobenzoic acid, were measured after spinal anesthesia with tetracaine which had been administered to patients under going orthopedic surgery. Tetracaine, an ester anesthetic, was given to 10 patients, the dose was 8-14mg, and blood samples were collected 1, 2 and 6h after the injection of tetracaine. We used gas chromatography/mass spectrometry for purposes of analysis. Tetracaine was not detected in any blood sample, but the metabolite was detected in each sample with the mean concentrations of 126.5, 97.9 and 43.3ng/ml at 1, 2 and 6h, respectively. This data will be useful in determination of the cause of death after spinal anesthesia with tetracaine.

Rationale for spinal anesthesia.

Spinal anesthesia is probably the most widely used form of regional anesthesia today. A number of clinical studies suggest that spinal anesthesia may be superior to general or epidural anesthesia for certain patients and for certain surgical procedures. The endocrine-metabolic response to surgery appears to be blunted when spinal anesthesia is employed compared to the response during general anesthesia. Blood loss and thromboembolic complications are also reduced when spinal anesthesia is used, particularly for major lower limb orthopedic procedures. Although long-term survival is not affected by the anesthetic technique employed, short-term mortality may be decreased in elderly patients having major orthopedic surgery under spinal anesthesia. Compared to epidural blockade, spinal anesthesia provides a more rapid onset, a more predictable level of analgesia, and a more profound degree of surgical anesthesia. On the other hand, spinal anesthesia is associated with a greater degree of hypotension compared to epidural anesthesia. The results of these various investigations show that a scientific rationale exists for the continued use of spinal anesthesia.

Prospective, multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly.

In a prospective randomized multi-centre study, the mortality following internal fixation surgery for fracture of the upper femur was investigated in 538 elderly patients allocated to receive subarachnoid blockade or general (narcotic-relaxant) anaesthesia. The 28-day mortality was 6.6% with subarachnoid, and 5.9% with general, anaesthesia. The difference was not significant (95% confidence limits: -3.5 to +4.8). At 1 year following surgery, the mortality was 20.4%. Increasing age, ischaemic heart disease, cardiac failure, preoperative arrhythmias and poor ASA status were all associated with increases in early and long term mortality. A delay to surgery of more than 24 h from admission was also associated with an increased 28-day mortality. Senile dementia and admission other than from the patient's own home, were factors associated with a poorer long term outcome. From the point of view of mortality, subarachnoid anaesthesia did not appear to confer any advantages over general anaesthesia in non-prosthetic surgery for hip fracture in the elderly.

Spinal or general anaesthesia for surgery of the fractured hip? A prospective study of mortality in 578 patients.

The mortality following surgical correction of upper femoral fractures was investigated in 578 patients, over the age of 50 yr, randomly allocated to receive spinal (bupivacaine) or general (enflurane or neurolept) anaesthesia. Thirty days after surgery the mortality was 6% after spinal and 8% after general anaesthesia (ns). Six months to 2 years after surgery the mortality was identical in the two groups. There were no differences with respect to ambulation and discharge. The estimated blood loss was smaller (P less than 0.05) in patients receiving spinal anaesthesia. Regardless of the anaesthetic technique, a high short-term mortality was related to age, male sex, and trochanteric fracture, whereas excess long-term mortality was related to male sex and high ASA scores.