Guay Joanne, Choi Peter T, Suresh Santhanam, Albert Natalie, Kopp Sandra, Pace Nathan Leon
From the Department of Anesthesiology, CSSS Rouyn-Noranda, Rouyn-Noranda, Quebec, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, Canada; Department of Pediatric Anesthesiology and Pediatrics, Northwestern University's Feinberg School of Medicine, Chicago, Illinois; Department of Anesthesiology, University Laval, Quebec, Canada; Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota; and Department of Anesthesiology, University of Utah, Salt Lake City, Utah.
Anesth Analg. 2014 Sep;119(3):716-725. doi: 10.1213/ANE.0000000000000339.
This analysis summarized Cochrane reviews that assess the effects of neuraxial anesthesia on perioperative rates of death, chest infections, and myocardial infarction.
A search was performed in the Cochrane Database of Systematic Reviews on July 13, 2012. We have included all Cochrane systematic reviews that examined subjects of any age undergoing any type of surgical (open or endoscopic) procedure, compared neuraxial anesthesia to general anesthesia alone for the surgical anesthesia, or neuraxial anesthesia plus general anesthesia to general anesthesia alone for the surgical anesthesia, and included death, chest infections, myocardial infarction, and/or serious adverse events as outcomes. Studies included in these reviews were selected on the same criteria.
Nine Cochrane reviews were selected for this overview. Their scores on the Overview Quality Assessment Questionnaire varied from 4 to 6 of a maximal possible score of 7. Compared with general anesthesia, neuraxial anesthesia reduced the 0- to-30-day mortality (risk ratio [RR] 0.71; 95% confidence interval [CI], 0.53-0.94; I = 0%) based on 20 studies that included 3006 participants. Neuraxial anesthesia also decreased the risk of pneumonia (RR 0.45; 95% CI, 0.26-0.79; I = 0%) based on 5 studies that included 400 participants. No difference was detected in the risk of myocardial infarction between the 2 techniques (RR 1.17; 95% CI, 0.57-2.37; I = 0%) based on 6 studies with 849 participants. Compared with general anesthesia alone, adding neuraxial anesthesia to general anesthesia did not affect the 0- to-30-day mortality (RR 1.07; 95% CI, 0.76-1.51; I = 0%) based on 18 studies with 3228 participants. No difference was detected in the risk of myocardial infarction between combined neuraxial anesthesia-general anesthesia and general anesthesia alone (RR 0.69; 95% CI, 0.44-1.09; I = 0%) based on 8 studies that included 1580 participants. Adding a neuraxial anesthesia to general anesthesia reduced the risk of pneumonia (RR 0.69; 95% CI, 0.49-0.98; I = 9%) after adjustment for publication bias and based on 9 studies that included 2433 participants. The quality of the evidence was judged as moderate for all 6 comparisons. The quality of the reporting score of complications related to neuraxial blocks was 9 (4 to 12 [median {range}]) for a possible maximum score of 14.
Compared with general anesthesia, neuraxial anesthesia may reduce the 0-to-30-day mortality for patients undergoing a surgery with an intermediate-to-high cardiac risk (level of evidence moderate). Large randomized controlled trials on the difference in death and major outcomes between regional and general anesthesia are required.
本分析总结了Cochrane系统评价，这些评价评估了椎管内麻醉对围手术期死亡率、肺部感染率和心肌梗死发生率的影响。
于2012年7月13日在Cochrane系统评价数据库中进行检索。我们纳入了所有Cochrane系统评价，这些评价研究了任何年龄接受任何类型手术（开放手术或内镜手术）的受试者，将椎管内麻醉与单纯全身麻醉用于手术麻醉进行比较，或将椎管内麻醉加全身麻醉与单纯全身麻醉用于手术麻醉进行比较，并将死亡、肺部感染、心肌梗死和/或严重不良事件作为结局指标。这些系统评价中纳入的研究是根据相同标准选择的。
本综述选择了9篇Cochrane系统评价。它们在综述质量评估问卷上的得分在最高可能得分7分中的4至6分之间。与全身麻醉相比，基于20项纳入3006名参与者的研究，椎管内麻醉降低了0至30天死亡率（风险比[RR]0.71；95%置信区间[CI]，0.53 - 0.94；I² = 0%）。基于5项纳入400名参与者的研究，椎管内麻醉也降低了肺炎风险（RR 0.45；95%CI，0.26 - 0.79；I² = 0%）。基于6项纳入849名参与者的研究，两种技术在心肌梗死风险方面未检测到差异（RR 1.17；95%CI，0.57 - 2.37；I² = 0%）。与单纯全身麻醉相比，基于18项纳入3228名参与者的研究，在全身麻醉基础上加用椎管内麻醉不影响0至30天死亡率（RR 1.07；95%CI，0.76 - 1.51；I² = 0%）。基于8项纳入1580名参与者的研究，椎管内麻醉联合全身麻醉与单纯全身麻醉在心肌梗死风险方面未检测到差异（RR 0.69；95%CI，0.44 - 1.09；I² = 0%）。在对发表偏倚进行校正后，基于9项纳入2433名参与者的研究，在全身麻醉基础上加用椎管内麻醉降低了肺炎风险（RR 0.69；95%CI，0.49 - 0.98；I² = 9%）。所有6项比较的证据质量被判定为中等。椎管内阻滞相关并发症报告得分的质量为9分（4至12分[中位数{范围}]），最高可能得分为14分。
与全身麻醉相比，椎管内麻醉可能降低中高心脏风险手术患者的0至30天死亡率（证据级别中等）。需要开展关于区域麻醉和全身麻醉在死亡及主要结局方面差异的大型随机对照试验。
