Outcome Studies Comparing Regional and General Anesthesia

Chapter

Key Points

  • Outcome studies of regional anesthesia are hindered by sample size issues and the possibility of selection bias; however, overall, regional techniques appear to offer benefits in the postoperative period.

  • Neuraxial anesthesia and analgesia provide significant reduction in pain following major surgery, but to date, its effects on mortality, morbidity, cardiovascular/respiratory complications, and postoperative delirium/cognitive dysfunction are inconclusive.

  • Results of studies investigating the effects of regional anesthesia on cancer recurrence are inadequate, although several prospective trials are currently underway.

  • The limited data available comparing regional anesthesia and general anesthesia suggests benefits for the former with respect to pain management, postoperative comfort, and discharge readiness.

Keywords

Outcome studies Regional anesthesia General anesthesia Morbidity/mortality Central neural blockade Peripheral nerve block Cognitive dysfunction Postoperative pain Discharge readiness 

References

  1. 1.
    Krumholz HM. Outcomes research: myths and realities. Circ Cardiovasc Qual Outcomes. 2009;2:1–3.CrossRefPubMedGoogle Scholar
  2. 2.
    Clancy CM, Eisenberg JM. Outcomes research: measuring the end results of health care. Science. 1998;282:245–6.CrossRefPubMedGoogle Scholar
  3. 3.
    Wu CL, Fleisher LA. Outcomes research in regional anesthesia and analgesia. Anesth Analg. 2000;91:1232–42.PubMedGoogle Scholar
  4. 4.
    Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg. 2007;104:689–702.CrossRefPubMedGoogle Scholar
  5. 5.
    Popping DM, Elia N, Marret E, Remy C, Tramer MR. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg. 2008;143:990–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Wu CL, Rowlingson AJ, Herbert R, Richman JM, Andrews RA, Fleisher LA. Correlation of postoperative epidural analgesia on morbidity and mortality after colectomy in Medicare patients. J Clin Anesth. 2006;18:594–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Hadzic A, Williams BA, Karaca PE, Hobeika P, Unis G, Dermksian J, Yufa M, Thys DM, Santos AC. For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology. 2005;102:1001–7.CrossRefPubMedGoogle Scholar
  8. 8.
    McCartney CJ, Brull R, Chan VW, Katz J, Abbas S, Graham B, Nova H, Rawson R, Anastakis DJ, von Schroeder H. Early but no long-term benefit of regional compared with general anesthesia for ambulatory hand surgery. Anesthesiology. 2004;101:461–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Nishimori M, Ballantyne JC, Low JH. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev. 2006; CD005059.Google Scholar
  10. 10.
    Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev. 2005; CD004088.Google Scholar
  11. 11.
    Desborough JP. The stress response to trauma and surgery. Br J Anaesth. 2000;85:109–17.CrossRefPubMedGoogle Scholar
  12. 12.
    Memtsoudis SG, Liu SS. Do neuraxial techniques affect perioperative outcomes? The story of vantage points and number games. Anesth Analg. 2014;119:501–2.CrossRefPubMedGoogle Scholar
  13. 13.
    Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan Jr JA, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290:2455–63.CrossRefPubMedGoogle Scholar
  14. 14.
    Borovskikh NA, Lebedev LV, Strashkov VI, Vinogradov AT. [Comparative evaluation of the effectiveness of epidural anesthesia with spontaneous respiration and general anesthesia in aorto-femoral bifurcation shunt]. Vestn Khir Im I I Grek. 1990; 145: 95–8.Google Scholar
  15. 15.
    Marret E, Remy C, Bonnet F. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. Br J Surg. 2007;94:665–73.CrossRefPubMedGoogle Scholar
  16. 16.
    Handoll HH, Madhok R, Dodds C. Anaesthesia for treating distal radial fracture in adults. Cochrane Database Syst Rev. 2002; CD003320.Google Scholar
  17. 17.
    Parker MJ, Handoll HH, Griffiths R. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev. 2001; CD000521.Google Scholar
  18. 18.
    Christopherson R, Beattie C, Frank SM, Norris EJ, Meinert CL, Gottlieb SO, Yates H, Rock P, Parker SD, Perler BA. Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Perioperative Ischemia Randomized Anesthesia Trial Study Group. Anesthesiology. 1993;79:422–34.CrossRefPubMedGoogle Scholar
  19. 19.
    Tuman KJ, McCarthy RJ, March RJ, DeLaria GA, Patel RV, Ivankovich AD. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg. 1991;73:696–704.CrossRefPubMedGoogle Scholar
  20. 20.
    Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000;321:1493.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Kooij FO, Schlack WS, Preckel B, Hollmann MW. Does regional analgesia for major surgery improve outcome? Focus on epidural analgesia. Anesth Analg. 2014;119:740–4.CrossRefPubMedGoogle Scholar
  22. 22.
    Davis FM, Laurenson VG. Spinal anaesthesia or general anaesthesia for emergency hip surgery in elderly patients. Anaesth Intensive Care. 1981;9(4):352–8.PubMedGoogle Scholar
  23. 23.
    McKenzie PJ, Wishart HY, Smith G. Long-term outcome after repair of fractured neck of femur. Comparison of subarachnoid and general anaesthesia. Br J Anaesth. 1984;56(6):581–5.CrossRefPubMedGoogle Scholar
  24. 24.
    McLaren AD, Stockwell MC, Reid VT. Anaesthetic techniques for surgical correction of fractured neck of femur. A comparative study of spinal and general anaesthesia in the elderly. Anaesthesia. 1978;33(1):10–4.CrossRefPubMedGoogle Scholar
  25. 25.
    Valentin N, Lomholt B, Jensen JS, Hejgaard N, Kreiner S. Spinal or general anaesthesia for surgery of the fractured hip? A prospective study of mortality in 578 patients. Br J Anaesth. 1986;58(3):284–91.CrossRefPubMedGoogle Scholar
  26. 26.
    Beattie WS, Badner NH, Choi P. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesth Analg. 2001;93:853–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Beattie WS, Badner NH, Choi PT. Meta-analysis demonstrates statistically significant reduction in postoperative myocardial infarction with the use of thoracic epidural analgesia. Anesth Analg. 2003;97:919–20.CrossRefPubMedGoogle Scholar
  28. 28.
    Yeager MP, Glass DD, Neff RK, Brinck-Johnsen T. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology. 1987;66:729–36.CrossRefPubMedGoogle Scholar
  29. 29.
    Guay J. The benefits of adding epidural analgesia to general anesthesia: a metaanalysis. J Anesth. 2006;20:335–40.CrossRefPubMedGoogle Scholar
  30. 30.
    Liu SS, Block BM, Wu CL. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: a meta-analysis. Anesthesiology. 2004;101:153–61.CrossRefPubMedGoogle Scholar
  31. 31.
    Park WY, Thompson JS, Lee KK. Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg. 2001;234:560–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Rigg JR, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW, Collins KS. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet. 2002;359:1276–82.CrossRefPubMedGoogle Scholar
  33. 33.
    Svircevic V, van Hijk D, Nierich AP, Passier MP, Kalkman CJ, van der Heijden GJ, Bax L. Meta-analysis of thoracic epidural anesthesia versus general anesthesia for cardiac surgery. Anesthesiology. 2011;114:271–82.CrossRefPubMedGoogle Scholar
  34. 34.
    Guay J, Choi PT, Suresh S, Albert N, Kopp S, Pace NL. Neuraxial anesthesia for the prevention of postoperative mortality and major morbidity: an overview of cochrane systematic reviews. Anesth Analg. 2014;119:716–25.CrossRefPubMedGoogle Scholar
  35. 35.
    Cook TM, Counsell D, Wildsmith JA. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth. 2009;102:179–90.CrossRefPubMedGoogle Scholar
  36. 36.
    Lawrence VA, Hilsenbeck SG, Noveck H, Poses RM, Carson JL. Medical complications and outcomes after hip fracture repair. Arch Intern Med. 2002;162:2053–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Parker M, Johansen A. Hip fracture. BMJ. 2006;333:27–30.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Radcliff TA, Henderson WG, Stoner TJ, Khuri SF, Dohm M, Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am. 2008;90:34–42.CrossRefPubMedGoogle Scholar
  39. 39.
    Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ. 2005;331:1374.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a meta-analysis. Anesth Analg. 2006;103:1018–25.CrossRefPubMedGoogle Scholar
  41. 41.
    Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anesthesia improve outcome after total knee arthroplasty? Clin Orthop Relat Res. 2009;467:2379–402.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Neuman MD, Silber JH, Elkassabany NM, Ludwig JM, Fleisher LA. Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults. Anesthesiology. 2012;117:72–92.CrossRefPubMedGoogle Scholar
  43. 43.
    McBrien ME, Shields MO, Heyburn G. Outcome by mode of anaesthesia for hip fracture surgery. Anaesthesia. 2014;69:640–1.CrossRefPubMedGoogle Scholar
  44. 44.
    Memtsoudis SG, Sun X, Chiu YL, Stundner O, Liu SS, Banerjee S, Mazumdar M, Sharrock NE. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology. 2013;118:1046–58.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Memtsoudis SG, Rasul R, Suzuki S, Poeran J, Danninger T, Wu C, Mazumdar M, Vougioukas V. Does the impact of the type of anesthesia on outcomes differ by patient age and comorbidity burden? Reg Anesth Pain Med. 2014;39:112–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Moller JT, Cluitmans P, Rasmussen LS, Houx P, Rasmussen H, Canet J, Rabbitt P, Jolles J, Larsen K, Hanning CD, Langeron O, Johnson T, Lauven PM, Kristensen PA, Biedler A, van Beem H, Fraidakis O, Silverstein JH, Beneken JE, Gravenstein JS. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet. 1998;351:857–61.CrossRefPubMedGoogle Scholar
  47. 47.
    Mashour GA, Woodrum DT, Avidan MS. Neurological complications of surgery and anaesthesia. Br J Anaesth. 2015;114:194–203.CrossRefPubMedGoogle Scholar
  48. 48.
    McDonagh DL, Mathew JP, White WD, Phillips-Bute B, Laskowitz DT, Podgoreanu MV, Newman MF. Cognitive function after major noncardiac surgery, apolipoprotein E4 genotype, and biomarkers of brain injury. Anesthesiology. 2010;112:852–9.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Newman MF, Kirchner JL, Phillips-Bute B, Gaver V, Grocott H, Jones RH, Mark DB, Reves JG, Blumenthal JA. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med. 2001;344:395–402.CrossRefPubMedGoogle Scholar
  50. 50.
    Steinmetz J, Christensen KB, Lund T, Lohse N, Rasmussen LS. Long-term consequences of postoperative cognitive dysfunction. Anesthesiology. 2009;110:548–55.CrossRefPubMedGoogle Scholar
  51. 51.
    Chan MT, Cheng BC, Lee TM, Gin T. BIS-guided anesthesia decreases postoperative delirium and cognitive decline. J Neurosurg Anesthesiol. 2013;25:33–42.CrossRefPubMedGoogle Scholar
  52. 52.
    Radtke FM, Franck M, Lendner J, Kruger S, Wernecke KD, Spies CD. Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. Br J Anaesth. 2013;110(Suppl 1):i98–i105.CrossRefPubMedGoogle Scholar
  53. 53.
    Sieber FE, Zakriya KJ, Gottschalk A, Blute MR, Lee HB, Rosenberg PB, Mears SC. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc. 2010;85:18–26.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Rasmussen LS, Johnson T, Kuipers HM, Kristensen D, Siersma VD, Vila P, Jolles J, Papaioannou A, Abildstrom H, Silverstein JH, Bonal JA, Raeder J, Nielsen IK, Korttila K, Munoz L, Dodds C, Hanning CD, Moller JT. Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients. Acta Anaesthesiol Scand. 2003;47:260–6.CrossRefPubMedGoogle Scholar
  55. 55.
    Mason SE, Noel-Storr A, Ritchie CW. The impact of general and regional anesthesia on the incidence of post-operative cognitive dysfunction and post-operative delirium: a systematic review with meta-analysis. J Alzheimers Dis. 2010;22(Suppl 3):67–79.CrossRefPubMedGoogle Scholar
  56. 56.
    Newman S, Stygall J, Hirani S, Shaefi S, Maze M. Postoperative cognitive dysfunction after noncardiac surgery: a systematic review. Anesthesiology. 2007;106:572–90.CrossRefPubMedGoogle Scholar
  57. 57.
    Wu CL, Hsu W, Richman JM, Raja SN. Postoperative cognitive function as an outcome of regional anesthesia and analgesia. Reg Anesth Pain Med. 2004;29:257–68.CrossRefPubMedGoogle Scholar
  58. 58.
    Heaney A, Buggy DJ. Can anaesthetic and analgesic techniques affect cancer recurrence or metastasis? Br J Anaesth. 2012;109(Suppl 1):i17–28.CrossRefPubMedGoogle Scholar
  59. 59.
    Biki B, Mascha E, Moriarty DC, Fitzpatrick JM, Sessler DI, Buggy DJ. Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: a retrospective analysis. Anesthesiology. 2008;109:180–7.CrossRefPubMedGoogle Scholar
  60. 60.
    Cummings III KC, Xu F, Cummings LC, Cooper GS. A comparison of epidural analgesia and traditional pain management effects on survival and cancer recurrence after colectomy: a population-based study. Anesthesiology. 2012;116:797–806.CrossRefPubMedGoogle Scholar
  61. 61.
    Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology. 2006;105:660–4.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Scavonetto F, Yeoh TY, Umbreit EC, Weingarten TN, Gettman MT, Frank I, Boorjian SA, Karnes RJ, Schroeder DR, Rangel LJ, Hanson AC, Hofer RE, Sessler DI, Sprung J. Association between neuraxial analgesia, cancer progression, and mortality after radical prostatectomy: a large, retrospective matched cohort study. Br J Anaesth. 2014;113(Suppl 1):i95–i102.CrossRefPubMedGoogle Scholar
  63. 63.
    Wuethrich PY, Hsu Schmitz SF, Kessler TM, Thalmann GN, Studer UE, Stueber F, Burkhard FC. Potential influence of the anesthetic technique used during open radical prostatectomy on prostate cancer-related outcome: a retrospective study. Anesthesiology. 2010;113:570–6.PubMedGoogle Scholar
  64. 64.
    Day A, Smith R, Jourdan I, Fawcett W, Scott M, Rockall T. Retrospective analysis of the effect of postoperative analgesia on survival in patients after laparoscopic resection of colorectal cancer. Br J Anaesth. 2012;109:185–90.CrossRefPubMedGoogle Scholar
  65. 65.
    Gottschalk A, Ford JG, Regelin CC, You J, Mascha EJ, Sessler DI, Durieux ME, Nemergut EC. Association between epidural analgesia and cancer recurrence after colorectal cancer surgery. Anesthesiology. 2010;113:27–34.CrossRefPubMedGoogle Scholar
  66. 66.
    Gottschalk A, Brodner G, Van Aken HK, Ellger B, Althaus S, Schulze HJ. Can regional anaesthesia for lymph-node dissection improve the prognosis in malignant melanoma? Br J Anaesth. 2012;109:253–9.CrossRefPubMedGoogle Scholar
  67. 67.
    Ismail H, Ho KM, Narayan K, Kondalsamy-Chennakesavan S. Effect of neuraxial anaesthesia on tumour progression in cervical cancer patients treated with brachytherapy: a retrospective cohort study. Br J Anaesth. 2010;105:145–9.CrossRefPubMedGoogle Scholar
  68. 68.
    Cakmakkaya OS, Kolodzie K, Apfel CC, Pace NL. Anaesthetic techniques for risk of malignant tumour recurrence. Cochrane Database Syst Rev. 2014; 11: CD008877.Google Scholar
  69. 69.
    Binczak M, Tournay E, Billard V, Rey A, Jayr C. Major abdominal surgery for cancer: does epidural analgesia have a long-term effect on recurrence-free and overall survival? Ann Fr Anesth Reanim. 2013;32:e81–8.CrossRefPubMedGoogle Scholar
  70. 70.
    Christopherson R, James KE, Tableman M, Marshall P, Johnson FE. Long-term survival after colon cancer surgery: a variation associated with choice of anesthesia. Anesth Analg. 2008;107:325–32.CrossRefPubMedGoogle Scholar
  71. 71.
    Myles PS, Peyton P, Silbert B, Hunt J, Rigg JR, Sessler DI. Perioperative epidural analgesia for major abdominal surgery for cancer and recurrence-free survival: randomised trial. BMJ. 2011;342:d1491.CrossRefPubMedGoogle Scholar
  72. 72.
    Tsui BC, Rashiq S, Schopflocher D, Murtha A, Broemling S, Pillay J, Finucane BT. Epidural anesthesia and cancer recurrence rates after radical prostatectomy. Can J Anaesth. 2010;57:107–12.CrossRefPubMedGoogle Scholar
  73. 73.
    Buggy DJ, Borgeat A, Cata J, Doherty DG, Doornebal CW, Forget P, Gottumukkala V, Gottschalk A, Gupta A, Gupta K, Hales TG, Hemmings HC, Hollmann MW, Kurz A, Ma D, Parat MO, Sessler DI, Shorten G, Singleton P. Consensus statement from the BJA Workshop on Cancer and Anaesthesia. Br J Anaesth. 2015;114:2–3.CrossRefPubMedGoogle Scholar
  74. 74.
    Hadzic A. Is regional anesthesia really better than general anesthesia? Anesth Analg. 2005;101:1631–3.CrossRefPubMedGoogle Scholar
  75. 75.
    Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg. 2005;101:1634–42.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Department of AnesthesiaCork University HospitalCorkIreland
  2. 2.ASSERT for Health CentreUniversity College CorkCorkIreland
  3. 3.Department of AnesthesiaSouth Infirmary Victoria University HospitalCorkIreland

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