Royal Victoria Hospital, Belfast Health and Social Care Trust, Grosvenor Road, Belfast BT12 6BA, UK.
Royal Victoria Hospital, Belfast Health and Social Care Trust, Grosvenor Road, Belfast BT12 6BA, UK.
Br J Anaesth. 2018 Jan;120(1):37-50. doi: 10.1016/j.bja.2017.09.002. Epub 2017 Nov 24.
Previous meta-analyses on the anaesthetic management of patients undergoing surgery for hip fracture have focused on randomized trials. Furthermore, heterogeneity in outcome reporting across the studies has made it difficult to inform best practice guidelines for patient care.
This systematic review examined how perioperative outcomes were reported and defined in the context of comparing modes of anaesthesia for hip fracture surgery. Outcomes were included from randomised and non-randomised studies published between January 2000 and July 2017. Meta-analyses were performed for regional versus general anaesthesia, with sensitivity analyses performed for spinal versus general anaesthesia.
By including data from 15 large observational studies in this meta-analysis, we have increased the number of patients for whom outcomes were assessed from approximately 3000 to 202 000. There was no significant difference in 30-day mortality (OR 1.02; 95% CI 0.96, 1.07, I2 31%; n=200 616), prevalence of pneumonia (OR 1.07; 95% CI 0.94, 1.23, I2 34%; n=65 011), acute myocardial infarction (OR 0.96; 95% CI 0.88, 1.04, I2 0%, n=64 904), delirium (OR 1.07; 95% CI 0.72, 1.58, I2 93%, n=19 923), or renal failure (OR 0.94; 95% CI 0.54, 1.64, I2 0%, n=27 873) for regional compared with general anaesthesia [corrected]. There was a small statistically significant difference for length of stay (standardized mean difference -0.03; 95% CI -0.05, -0.02; I 0%; n=78 711) favouring regional anaesthesia, which is unlikely to be clinically significant. Sensitivity analyses for the same outcomes examining spinal only vs general anaesthesia showed minor statistical significance for length of stay favouring spinal. We also present data highlighting the scale of the inconsistencies in reported outcomes across 32 studies, making evaluation in a standardized manner very difficult. As an example, mortality was reported in nine different ways throughout the studies.
We highlight the need for agreement on outcome definitions and for a minimum core outcome set to be measured and reported in hip fracture studies. This would strengthen the evidence-based approach to delivering optimal care.
先前关于髋部骨折手术患者麻醉管理的荟萃分析侧重于随机试验。此外，由于研究之间的结果报告存在异质性，因此难以制定最佳的患者护理指南。
本系统评价研究了在比较髋部骨折手术的麻醉方式时，围手术期结果的报告和定义方式。纳入了 2000 年 1 月至 2017 年 7 月期间发表的随机和非随机研究中的结果。对区域麻醉与全身麻醉进行了荟萃分析，并对脊髓麻醉与全身麻醉进行了敏感性分析。
通过纳入这项荟萃分析中 15 项大型观察性研究的数据，我们将评估结果的患者人数从大约 3000 例增加到 202000 例。30 天死亡率（OR 1.02；95%CI 0.96，1.07，I2 31%；n=200616）、肺炎发生率（OR 1.07；95%CI 0.94，1.23，I2 34%；n=65011）、急性心肌梗死（OR 0.96；95%CI 0.88，1.04，I2 0%；n=64904）、谵妄（OR 1.07；95%CI 0.72，1.58，I2 93%；n=19923）和肾功能衰竭（OR 0.94；95%CI 0.54，1.64，I2 0%；n=27873）方面，区域麻醉与全身麻醉相比没有显著差异[校正]。对于住院时间（标准化均数差-0.03；95%CI -0.05，-0.02；I 0%；n=78711），区域麻醉略有统计学意义，这可能没有临床意义。对于同样的结果，仅对脊髓麻醉与全身麻醉进行敏感性分析，结果表明脊髓麻醉有利于住院时间的缩短。我们还提供了数据，突出显示了 32 项研究中报告的结果不一致的程度，使得以标准化方式进行评估非常困难。例如，在整个研究中，死亡率以九种不同的方式报告。
我们强调需要就结果定义达成一致，并需要制定一个最小的核心结果集，以在髋部骨折研究中进行测量和报告。这将加强提供最佳护理的循证方法。
