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Kardioprotektion durch thorakale Periduralanästhesie?

Metaanalyse

Cardioprotection by thoracic epidural anesthesia?

Meta-analysis

  • Regionalanästhesie
  • Published:
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Zusammenfassung

Hintergrund

Bislang wird vermutet, dass der Einsatz einer thorakalen Periduralanästhesie (PDA) bei nichtherzchirurgischen Operationen kardioprotektive Effekte bietet. Zwei frühere Metaanalysen ergaben kontroverse Ergebnisse zum Einfluss einer PDA auf das Überleben. Ziel der aktuellen Metaanalyse auf der Basis prospektiver Studien war die Klärung der Frage, ob die thorakale PDA die kardiale Morbidität oder die Mortalität reduziert.

Material und Methoden

Es wurde eine systematische Literatursuche, basierend auf medizinischen Datenbanken (Medline, EBM-Reviews, Embase, Biosis und Biological Abstracts) durchgeführt. Relevante Studien wurden von 2 unabhängigen Untersuchern evaluiert. In die Metaanalyse wurden bis Ende 2008 publizierte randomisierte Studien mit der Frage des Einflusses einer thorakalen PDA auf das „outcome“ bei nichtherzchirurgischen Operationen eingeschlossen. Die Berechnungen erfolgten mit dem Statistikprogramm Review-Manager 4.1 unter Annahme fixer Effekte („fixed effects model“).

Ergebnisse

Es wurden 9 Studien mit 2768 Patienten in die Metaanalyse aufgenommen. Die thorakale PDA reduzierte die postoperative Mortalität nicht [“odds ratio“ (Peto OR): 1,08; 95%-Konfidenzintervall (95%-KI) 0,74–1,58]. Die Myokardinfarktrate wurde nur tendenziell, aber nicht signifikant gesenkt (Peto OR: 0,65; 95%-KI 0,4–1,05).

Schlussfolgerung

Aufgrund der vorliegenden Metaanalyse ergibt sich kein Hinweis, dass durch die thorakale PDA die perioperative Mortalität bei nichtherzchirurgischen Eingriffen gesenkt werden kann. Ein günstiger Effekt auf die Myokardinfarktrate bleibt weiterhin fraglich.

Abstract

Background

Thoracic epidural analgesia (EDA) is thought to provide cardioprotective effects in patients undergoing noncardiac surgery. The results of two previous meta-analysis showed controversial conclusions regarding the impact of EDA on perioperative survival. The purpose of the present meta-analysis was to evaluate, whether thoracic EDA has the potential to reduce perioperative cardiac morbidity or mortality on the basis of available randomized controlled trials.

Patients and methods

A systematic literature search was conducted in medical databases (Med-Line, EBM-Reviews, Embase, Biosis and Biological Abstracts) and relevant clinical trials including patients undergoing noncardiac surgery were evaluated by two independent investigators. All randomized controlled trials investigating the effects of thoracic EDA on perioperative outcome, published from 1980 up to the end of 2008 were included into this quantitative systematic review. Calculations were performed using the statistics program Review Manager 4.1 using a fixed-effects model.

Results

Nine studies with a total of 2,768 patients were included in the meta-analysis. Thoracic EDA did not reduce perioperative mortality [odds ratio (Peto OR): 1.08; 95% confidence interval (CI) 0.74–1.58]. Patients receiving thoracic EDA demonstrated a tendency to a lower rate of perioperative myocardial infarction. However, this effect of thoracic EDA did not reach statistical significance (Peto OR: 0.65; 95% CI 0.4–1.05).

Conclusions

The present meta-analysis did not prove any positive influence of thoracic EDA on perioperative in-hospital mortality in patients undergoing noncardiac surgery. Furthermore, it remains questionable if thoracic EDA has the potential to reduce the rate of perioperative myocardial infarction.

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Danksagung

Die Autoren bedanken sich bei Prof. Dr. Rainer Muche, Institut für Biometrie der Universität Ulm, für seine freundliche Beratung und Hilfe bei den statistischen Analysen.

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

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  1. Klinik für Anästhesiologie, Universitätsklinikum Ulm, Steinhövelstr. 9, 89075, Ulm, Deutschland

    A. Gauss, W. Stahl, M. Rockemann, M. Georgieff, F. Wagner & R. Meierhenrich

  2. Spital Zimmerberg, Horgen, Schweiz

    S.K. Jahn

  3. Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Gießen u. Marburg GmbH, Marburg, Deutschland

    L.H.J. Eberhart

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  1. A. Gauss
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Gauss, A., Jahn, S., Eberhart, L. et al. Kardioprotektion durch thorakale Periduralanästhesie?. Anaesthesist 60, 950–962 (2011). https://doi.org/10.1007/s00101-011-1941-9

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