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Anaesthesia for hip fracture surgery in adults

  1. Martyn J Parker1,*,
  2. Helen HG Handoll2,
  3. Richard Griffiths3

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 18 OCT 2004

Assessed as up-to-date: 10 JUN 2004

DOI: 10.1002/14651858.CD000521.pub2


How to Cite

Parker MJ, Handoll HHG, Griffiths R. Anaesthesia for hip fracture surgery in adults. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD000521. DOI: 10.1002/14651858.CD000521.pub2.

Author Information

  1. 1

    Peterborough and Stamford Hospitals NHS Foundation Trust, Department of Orthopaedics, Peterborough, Cambridgeshire, UK

  2. 2

    Teesside University, Health and Social Care Institute, Middlesbrough, Tees Valley, UK

  3. 3

    Peterborough and Stamford Hospitals NHS Foundation Trust, Department of Anaesthesia, Peterborough, Cambridgeshire, UK

*Martyn J Parker, Department of Orthopaedics, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough City Hospital, CBU PO Box 211, Bretton Gate, Peterborough, Cambridgeshire, PE3 9GZ, UK. martyn.parker@pbh-tr.nhs.uk.

Publication History

  1. Publication Status: Unchanged
  2. Published Online: 18 OCT 2004

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This is not the most recent version of the article. View current version (22 FEB 2016)

 
Characteristics of included studies [ordered by study ID]
Adams 1990

MethodsQuasi-randomised trial: by the date of operation


ParticipantsOrthopaedic hospital in Gieben, Germany
56 patients with a proximal femoral fracture.
Mean age 79/81 years (range 63-91).
Male: 18%
Number lost to follow-up: not stated


InterventionsSpinal anaesthesia using 0.5% bupivacaine and 4% mepivacaine
versus
General anaesthesia using halothane, nitrous oxide/oxygen, vecuronium, succinylcholine, atropine


OutcomesLength of follow up: period of hospital stay
Mortality - during hospital stay
Length of operation
Hypotension
Operative blood loss
Transfusion requirements
Length of hospital stay
Blood levels of catecholamines, ADH and adrenaline (see notes)
Pneumonia (f)
Congestive cardiac failure (f)
Renal failure
Pulmonary embolism (f)


NotesPublished in German
Abstract and diagrams are contradictory for endocrine (ADH, adrenalin) results


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)High riskC - Inadequate

Berggren 1987

MethodsRandomised trial: method not stated


ParticipantsOrthopaedic hospital in Umea, Sweden.
57 patients with a femoral neck fracture
Mean age 77/78 years (range 65-92 years).
Male: 19%
Number lost to follow-up: 4 (7%)


InterventionsBoth groups premedicated with pethidine 25-50 mg.
Spinal anaesthesia with 2% prilocaine in the epidural space, mean volume used 12.5 ml
versus
General anaesthesia with thiopentone 3-4 mg/kg, atropine 0.25-0.5 mg IV, succinylcholine ventilated with nitrous oxide and oxygen and halothane and succinylcholine infusion


OutcomesLength of follow up: 12 months
Mortality - 1 year (see notes)
Length of operation
Operative hypotension
Intraoperative blood loss (not split by treatment groups)
Hypoxaemia
Length of hospital stay
Pneumonia
Cerebrovascular accident
Congestive cardiac failure
Confusional state
Urine retention
Urinary tract infection
Pulmonary embolism
Total medical complications


Notes4 died by 1 year, 1 in the epidural group on 1st post-op day, the other 3 (group not given) by 5 months.
Patients were interviewed at 6 and 12 months regarding living conditions and walking ability - data not presented.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Biffoli 1998

MethodsRandomised trial: method not stated


ParticipantsDistrict hospital in Italy.
60 patients with a femoral neck fracture aged 70 years and above
Mean age 83 years (range not stated)
Male: 13%
Number lost to follow-up: probably none


InterventionsSpinal anaesthesia with a mean dose of 12.7 mg hyperbaric bupivacaine 1%
versus
General anaesthesia with propofol 1 mg/kg, atracurium besilate 0.5 mg/kg, nitrous oxide, isoflurane, atracurium infusion of 0.5 mg/kg/hr and fentanyl [fentanile] 1 ug/kg as required


OutcomesLength of follow up: 2 days
Length of operation (intervention)
Operative hypotension
Postoperative hypoxia
Confusional state


NotesIn Italian.
Patient group split into 2 groups depending on preoperative mental state: 38 who were not confused and 22 who were.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Bigler 1985

MethodsRandomised trial: method not stated


ParticipantsPlace and country of study not stated
40 patients with a proximal femoral fracture
Mean age 79 years.
Male: 17.5%
Loss to follow-up: not known


InterventionsSpinal anaesthesia with 3 ml of 0.75% bupivacaine
versus
General anaesthesia using atropine, fentanyl, pancuronium, nitrous oxide/oxygen, diazepam and suxamethonium


OutcomesLength of follow up: 3 months
Mortality - early
Length of operation
Hypotension (maximum drop in systolic blood pressure)
Transfusion requirements
Fall in haemoglobin
Pneumonia
Cerebrovascular accident
Congestive cardiac failure
Confusional state
Urine retention
Postoperative vomiting
Pulmonary embolism
Time till ambulation
Mental function
Headache


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Bredahl 1991

MethodsRandomised trial: method not stated


ParticipantsOrthopaedic hospital Aalborg, Denmark
30 female patients with a proximal femoral fracture
Mean age 79 years (range 60-90).
Male: 0%
Loss to follow-up: not stated, but 2 excluded due to incomplete data.


InterventionsSpinal anaesthesia with 2.5-3 ml of 0.5% bupivacaine
versus
General anaesthesia using thiopentone, pethidine, pancuronium, nitrous oxide/oxygen, IPPV, and suxamethonium


OutcomesLength of follow up: 3 days
Length of operation
Operative blood loss
Change in body temperature (up to 3 hours)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Brichant 1995

MethodsRandomised trial: method not stated


ParticipantsOrthopaedic hospital in Brussels, Belgium
106 patients with proximal femoral fracture
Age: not stated.
Male: % not stated
Number lost to follow-up: not stated


InterventionsSpinal (subarachnoid or epidural) anaesthesia with bupivacaine
versus
General anaesthesia administered according to 'local practice'


OutcomesLength of follow up: 10 days
Deep vein thrombosis (venography)
Pulmonary embolism
Haemorrhagic complications
Thrombocytopenia


NotesConference abstract only
All patients had subcutaneous nadroparin for DVT prophylaxis


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Brown 1994

MethodsRandomised trial: use of random numbers table


ParticipantsOrthopaedic hospital in Hong Kong
20 patients with a proximal femoral fracture
Mean age 77 years (range 66-91).
Male: 50%
Number lost to follow-up: not stated


InterventionsPre-medication with pethidine or temazepam

Spinal (subarachnoid) anaesthesia with 0.2 mg/kg hyperbaric bupivacaine
versus
General anaesthesia using thiopentone or propofol, isoflurane or enflurane, atracurium and nitrous oxide/oxygen


OutcomesLength of follow up: 2 days (up to 44 hours)
Hypotension
Oxygen saturation


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Casati 2003

MethodsRandomised trial: by sealed envelopes


ParticipantsOrthopaedic hospital in Milan, Italy
30 patients of ASA grade II or III undergoing hemiarthroplasty for a proximal femoral fracture.
Mean age 84 years (range 67-94).
Male: 7%
Number lost to follow-up: 0


InterventionsSpinal anaesthesia with 7.5 mg of hyperbaric bupivacaine
versus
General anaesthesia with sevoflurane inhalation and laryngeal mask airway


OutcomesLength of follow up: 7 days & hospital discharge
Length of operation
Operative blood loss
Operative hypotension
Bradycardia
Time in theatre recovery department
Mini mental test score (day 1 and 7)
Confusion (day 7)
Pain
Length of hospital stay


NotesFentanyl (1 ug/kg) given before induction of either general or spinal anaesthesia


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Couderc 1977

MethodsRandomised study: by 'drawing of lots'


ParticipantsOrthopaedic hospital in Paris, France
100 patients with a proximal femoral fracture
Mean age 86 years. (Inclusion criterion: 80+ years; range not stated).
Male: 14%
Number lost to follow-up: not stated


InterventionsSpinal anaesthesia with 0.5% bupivacaine and adrenaline
versus
General anaesthesia with thiopentone, pancuronium or succinylcholine, dextromoramide or methoxyflurane, nitrous oxide/oxygen


OutcomesLength of follow up: 3 months
Mortality - 11 days, 3 months
Hypotension
Transfusion requirements
Oxygenation and carbon dioxide levels
Myocardial infarction (f)
Cerebrovascular accident (f)
Pulmonary embolism (f)


NotesIn French
Complete data for fatal myocardial infarction, congestive heart failure and pulmonary embolism not provided.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Davis 1981

MethodsRandomised trial: method not stated


ParticipantsOrthopaedic hospital Christchurch, New Zealand
132 patients with a proximal femoral fracture
Mean age 81/78 years (Inclusion criterion: 50+, range not given).
Male: 15%
Number lost to follow-up: 0


InterventionsSpinal anaesthesia using tetracaine 0.5% in 51 patients and 0.5% cinchocaine in 13 patients. Ketamine also used for sedation in 8 patients. Sedation also provided with diazepam (mean dose 9 mg)
versus
General anaesthesia with diazepam (2.5-30 mg) mean dose 9.5 mg, fentanyl 1-3 ug/kg, nitrous oxide and oxygen, IPPV, pancuronium (mean dose 6 mg)


OutcomesLength of follow up : 1 month
Mortality - 1 month
Duration of anaesthesia (Length of operation)
Postoperative blood gases
Hypotension
Operative blood loss
Fall in haematocrit
Pneumonia (f)
Aspiration pneumonia (f)
Myocardial infarction (f)
Cerebrovascular accident
Congestive cardiac failure
Renal failure
Cardiac arrhythmias
Deep vein thrombosis (fibrinogen)
Pulmonary embolism (f)


Notes8 failed spinals who had a general anaesthesia were placed in the general anaesthesia group.
Results for DVT were available for 76 out of a subgroup of 90 patients who were monitored using I125 fibrogen scanning


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Davis 1987

MethodsRandomised trial: method not stated


ParticipantsOrthopaedic hospitals in New Zealand - multicentre study
549 patients with a proximal femoral fracture
Mean age 79.5 years (range not stated).
Male: 22%
Number lost to follow-up: 0, but 11 excluded


InterventionsSpinal anaesthesia with sedation with diazepam. Tetracaine, nupercaine or bupivacaine for spinal
versus
General anaesthesia with pre-oxygenation, IV induction with thiopentone, IPPV maintained with nitrous oxide/oxygen, non-depolarizing neuromuscular blocker, fentanyl


OutcomesLength of follow up: 3 to 30 months
Mortality - 1 month, 3 & 6 months (estimated from graph)
Hypotension
Length of hospital stay
Pneumonia (f)
Myocardial infarction (f)
Cerebrovascular accident (f)
Congestive cardiac failure (f)
Renal failure (f)
Pulmonary embolism (f)


Notes11.3% of patients originally allocated to spinal anaesthesia were given general anaesthesia due to failed spinals. These were retained in the spinal group for analysis purposes.
There was 1 non fatal anaphylactoid reaction at induction of general anaesthesia


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

de Visme 2000

MethodsRandomised trial: method by 'hospital pharmacy before transfer to the operating theatre'


ParticipantsOrthopaedic hospital in Brest, France
29 patients with a proximal femoral fracture
Mean age 85 years (range 68-97).
Male: 17%
Number lost to follow-up: none


InterventionsSpinal anaesthesia with sedation using alfentanil and 3 ml 0.5% plain bupivacaine for the spinal
versus
Lumber plexus, sacral plexus and iliac crest block first with sedation using alfentanil. 30 ml and 10 ml of 1.33% lidocaine and adrenaline [epinephrine] were used for the lumbar and sacral blocks and 5 ml 1% lidocaine for the iliac crest block (for lateral cutaneous nerve)


OutcomesLength of follow up: not stated but probably 5 days
Length of operation
Time to perform the anaesthetic
Hypotension
Use of adrenaline [epinephrine] during surgery
Postoperative cognitive function
Pain levels in the recovery room
Need for supplementation of analgesia


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Eyrolle 1998

MethodsRandomised trial: method not stated


ParticipantsOrthopaedic hospital in Paris, France
50 patients with a proximal femoral fracture
Mean age 82 years (range not stated)
Male: % not stated
Number lost to follow-up: none probably


InterventionsSpinal anaesthesia with 0.5% bupivacaine
versus
lumber plexus block using 2% lidocaine, 0.5% bupivacaine with 1:200,000 epinephrine.
A light sedation with propofol intravenously, as required


OutcomesLength of follow up: not stated
Ease of insertion
Hypotension
Use of propofol during surgery (associated with discomfort)
Use of epinephrine during surgery
Postoperative cognitive function
Pain levels post-operatively
Adverse effects (including urinary retention)


NotesConference abstract only


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Juelsgaard 1998

MethodsRandomised trial: method not stated


ParticipantsOrthopaedic hospital in Aarhus, Denmark
29 followed-up out of 54 patients with proximal femoral fracture and known coronary artery disease
For 29 patients included in this review:
Age: mean 80.9 years (range 65-99)
Male: 13%
Number lost to follow-up: 0, but 11 excluded from original trial population


InterventionsSpinal anaesthesia with 2.5 ml of 0.5% bupivacaine in the subarachnoid space
versus
General anaesthesia with fentanyl 1-2 mcg/kg, 1-4 mg/kg thiopentone, 0.5 mg/kg atracurium, nitrous oxide and oxygen, enflurane


OutcomesLength of follow up: 1 month
Mortality - 1 month
Length of operation
Hypotension (33% reduction from baseline)
Peri- and postoperative blood loss
Transfusion requirements
Pneumonia (f)
Congestive cardiac failure (f)
Myocardial infarction
ECG analysis
Length of hospital stay


NotesThe study also included 14 patients allocated to incremental spinal anaesthesia. These patients have not been included in this review


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Kamitani 2003

MethodsRandomised trial: method not stated


Participants40 patients with a femoral neck fracture
Mean age 82 years (range - not stated).
Male: 10%
Number lost to follow-up: 0


InterventionsSpinal anaesthesia with 3 ml of 0.5% isobaric bupivacaine
versus
General anaesthesia with propofol (0.5-1 mg), vecuronium (0.5-1 mg/kg), nitrous oxide, sevoflurane and fentanyl (0.1-0.2 mg/kg) and local field block with local anaesthesia


OutcomesLength of follow up: 4 days
Length of surgery
Length of anaesthesia
Intraoperative blood loss
Transfusion requirements
Haemoglobin
Urine output
Oxygen saturation
Delirium (day 1,2,3 & 4)
Analgesic use


NotesIn Japanese


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Maurette 1988

MethodsRandomised trial: by 'random draw'


ParticipantsOrthopaedic hospital Bordeaux, France
35 patients with a proximal femoral fracture
Mean age 83 years (range not stated).
Male: % not stated
Number lost to follow-up: not stated, but 2 excluded as they failed to participate in post-op tests


InterventionsSpinal anaesthesia with 1.5 mg/kg prilocaine
versus
General anaesthesia using thiopentone, spontaneous ventilation, nitrous oxide/oxygen, enflurane, dextromoramide


OutcomesLength of follow up: 3 days
Length of operation
Hypotension
Transfusion requirements
Psychological evaluation


NotesIn French


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

McKenzie 1984

MethodsRandomised trial: use of envelopes containing random numbers


ParticipantsOrthopaedic hospital in Glasgow, Scotland
150 patients with fractured neck of femur.
Mean age 75 years (range not stated).
Male: % not stated
Number lost to follow-up: 0, but 2 excluded due to postponement of operation


InterventionsSpinal anaesthesia with 0.5% hyperbaric cinchocaine 1.3-1.5 ml. Supplemented by small doses of diazepam if required
versus
General anaesthesia induced with althesin 1-3 ml, suxamethonium 50 mg, nitrous oxide and oxygen, halothane and spontaneous respiration


OutcomesLength of follow up: 12 months
Mortality - at 1, 3, 6 and 12 months
Length of operation
Operative blood loss
Length of hospital stay
Pneumonia (f)
Myocardial infarction (f)
Cerebrovascular accident (f)
Deep vein thrombosis (venography)
Pulmonary embolism (f)
Location at 12 months


NotesAdditional information supplied by Dr McLaren indicated that all the references refered to one study. Additional data on mortality supplied.
The venography study for DVT detection involved a subgroup of 40 patients


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskA - Adequate

McLaren 1978

MethodsRandomised trial: method not stated


ParticipantsOrthopaedic hospital in Glasgow, Scotland
116 patients with fractured neck of femur
Mean age 76 years.
Male: % not stated.
Number lost to follow-up: none for the original report of 55 cases. Loss to follow up not reported in the later study report (1982) of 116 cases.


InterventionsNo premedication
Spinal anaesthesia with 0.5 ml hyperbaric cinchocaine 0.5%. Patients sedated with 10% althesin in 5% dextrose during operation.
versus
General anaesthesia with althesin 50 mcg/kg, pancuronium bromide 0.1 mg/kg, IPPV, nitrous oxide, oxygen and fentanyl 0.05 mg as needed


OutcomesLength of follow up: 1 month minimum
Mortality - 1 month
Length of operation
Hypotension
Postoperative oxygenation
Blood loss
Pneumonia (f)
Vomiting
Myocardial infarction (f)
Renal failure (f)
Deep vein thrombosis (f)
Pulmonary embolism (f)
Headache (none)


NotesThe original paper in 1978 reported the results for 55 cases. A later report in 1982 of the same study gave the outcome for 116 patients. The latter report was used for the outcomes of mortality at one month, fatal pneumonia, fatal pulmonary embolism, fatal renal failure and fatal myocardial infarction. The original paper was used for the other outcomes for 55 patients. The methodology assessment was based on the 1978 report.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Racle 1986

MethodsRandomised study: use of random numbers table


ParticipantsOrthopaedic hospital in Cedex, France.
70 female patients with a proximal femoral fracture
Mean age: 82 years (Inclusion criterion: 75+, range not given).
Male: 0%
Number lost to follow-up: not stated


InterventionsSpinal anaesthesia with 3 ml 0.5% bupivacaine + adrenaline
versus
General anaesthesia using thiopentone, vecuronium, fentanyl, nitrous oxide/oxygen, enflurane


OutcomesLength of follow up: 3 months
Mortality - 1, 3 months
Length of operation
Hypotension
Transfusion requirements
Length of hospital stay
Pneumonia
Myocardial infarction
Cerebrovascular accident (f)
Congestive cardiac failure
Renal failure (f)
Confused state
Pulmonary embolism


NotesIn French


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Spreadbury 1980

MethodsRandomised: method not stated


ParticipantsOrthopaedic hospital in Warwick, England
60 female patients with a proximal femoral fracture
Mean age 84 years (range not stated).
Male: % not stated
Number lost to follow-up: none


InterventionsKetamine anaesthesia using atropine pre-medication: ketamine 2 mg/kg at induction then ketamine 1 mg/kg as required. Also optional diazepam
versus
General anaesthesia using premedication of atropine 0.6 mg then a general anaesthetic using drugs and method chosen by the anaesthetist


OutcomesLength of follow up: not stated
Mortality - 14 days, during hospital stay
Myocardial infarction (f)
Congestive cardiac failure (f)
Pulmonary embolism (f)
Time to mobilisation
Length of hospital stay
Return of patients back home
Occurrence of dreams or hallucinations after operation
Unsatisfactory surgical results


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Svarting 1986

MethodsRandomised trial: method not stated


ParticipantsUniversity hospital in Helsinki, Finland
30 patients with a proximal femoral fracture treated with a Thompson prosthesis. (ASA grade II OR III.)
Mean age 77 years (range not stated).
Male: 13%
Number lost to follow-up: none likely


InterventionsBoth groups premedicated with pethidine and atropine

Spinal anaesthesia using 3 ml of 0.5% isobaric bupivacaine into the subarachnoidal space
versus
General anaesthesia using fentanyl, thiopental, pancuronium bromide, nitrous oxide/oxygen, then atropine and neostigmine


OutcomesLength of follow up: not stated
Length of operation
Hypotension
Operative blood loss
Transfusion requirements
Arterial oxygen tension
Plasma cortisol levels


NotesEmphasis in the article on the connection of the results with the use of methylmethacrylate cement for the Thompson prosthesis


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Tasker 1983

MethodsRandomised trial: method not stated


ParticipantsOrthopaedic hospital in Leicester, England
100 patients with a proximal femoral fracture.
Mean age not stated.
Male: % not stated
Number lost to follow-up: not stated


InterventionsSpinal versus general anaesthesia
Exact method of anaesthesia not stated


OutcomesLength of follow up: not stated
Mortality
Plasma catecholamines, cortisol


NotesConference abstract only


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Ungemach 1993

MethodsRandomised trial: method not stated, mention of pairs


ParticipantsOrthopaedic hospital in Mannheim, Germany
114 patients with a proximal femoral fracture.
Mean age 79 years (range not stated).
Male: 16%
Number lost to follow-up: not stated


InterventionsSpinal anaesthesia with 3-4 ml of 0.5% hyperbaric bupivacaine
versus
General anaesthesia with isoflurane, fentanyl, nitrous oxide/oxygen


OutcomesLength of follow up: 2 weeks
Mortality - 2 weeks
Score based on conscious level, respiration, circulation, blood lost and laboratory tests taken at 2 hours.
Score based on lab tests, cardiopulmonary situation and complications (e.g. heart failure, thrombosis and apoplexy) at 2 weeks post-operatively


NotesConference abstract only


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Valentin 1986

MethodsRandomised trial: method not stated


ParticipantsOrthopaedic hospital in Hellerup, Denmark
662 patients with a proximal femoral fracture
Mean age 79 years (range 50 - 100).
Male: 20%
Number lost to follow-up: 2 (0.3%), 84 patients excluded


InterventionsSpinal anaesthesia with 3-4 ml isotonic bupivacaine and sedation with fentanyl 0.05-0.1 mg IV
versus
General anaesthesia with enflurane and nitrous oxide/oxygen with or without thiopentone at induction or neurolept anaesthesia with droperidol, fentanyl and nitrous oxide/oxygen


OutcomesLength of follow up: 24 months
Mortality - 1 month, 3, 6 and 12 months (read from graphs)
Length of operation
Operative blood loss
Time to ambulation
Length of hospital stay


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Wajima 1995

MethodsRandomised trial: method not stated


ParticipantsHospital in Higashine, Japan
41 patients with a femoral neck fracture
Mean age 80 (range: inclusion criteria ages 70-90 years).
Male: 22%
Number lost to follow-up: Probably none


InterventionsSpinal anaesthesia with continuous infusion of bupivacaine and butorphanol for 72 hours postoperatively
versus
General anaesthesia with thiopental, succinylcholine, nitrous oxide and sevoflurane


OutcomesLength of follow up: 1 week
Hasegawa dementia scale score(presented graphically)


NotesIn Japanese


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

White 1980

MethodsRandomised trial: method not stated


ParticipantsOrthopaedic hospital in Cape Town, South Africa
40 of 60 patients in trial with a proximal femoral fracture.
Mean age 79 years (range not stated).
Male: 8%
Number lost to follow-up: 0


InterventionsSpinal anaesthesia with 0.6-0.8 ml hyperbaric cinchocaine and 'light' general anaesthesia with althesin, fentanyl, nitrous oxide/oxygen
versus
General anaesthesia with thiopentone, suxamethonium, nitrous oxide/oxygen, halothane, fentanyl
versus
Psoas nerve block with 30 ml 2% mepivacaine and 'light' general anaesthesia with fentanyl and althesin (not included in review)


OutcomesLength of follow up: minimum 4 weeks
Mortality - 1 month
Length of operation
Postoperative blood gases (oxygen and carbon dioxide)
Pneumonia
Confusional state
Deep vein thrombosis
Vomiting


NotesThe 20 Psoas nerve block group patients were not included in this review


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Alonso Chico 2003This randomised trial of 60 hip fracture patients compared spinal anaesthesia with bupivacaine and fentanyl versus bupivacaine alone. The trial was excluded as it was not a trial of different types of anaesthesia but a comparison of different drugs within one form of anaesthesia.

Barna 1981Translation of the article from Hungarian revealed it is a comparative study of 100 spinal anaesthetics and 100 general anaesthetics for hip fracture patients. The study was excluded as there was no randomisation of patients.

Ben-David 2000This randomised trial of 20 hip fracture patients compared spinal anaesthesia with bupivacaine and fentanyl versus bupivacaine alone. The trial was excluded as it was not a trial of different types of anaesthesia but a comparison of different drugs within one form of anaesthesia.

Coleman 1988A randomised trial of 152 patients comparing general anaesthesia with spontaneous respiration with general anaesthesia with controlled ventilation. The study was excluded as it involved a change in the types of drugs used only, not a change in the method of anaesthesia.

Critchley 1995A randomised trial of 30 hip fracture patients comparing spinal anaesthesia with ephedrine alone or with ephedrine and colloid. The trial was excluded as it was not a trial of different types of anaesthesia but a comparison of different drugs within one form of anaesthesia.

Darling 1994A randomised trial of 10 patients with spinal anaesthetic and 10 with general anaesthesia to assess the rate of clearance of a bolus dose of Indocyanine green between the two anaesthetic techniques. There was no difference in the rate of disappearance of the indocyanine green between the two techniques and no other outcomes were reported. The study was excluded as it was not felt relevant to this review as no clinical outcomes were reported.

Dyson 1988A randomised trial of 60 patients which tested the use of postoperative oxygen in two groups that had already been divided into those receiving general anaesthesia and those receiving spinal anaesthesia. No results were provided for the anaesthetic comparison save the general statement that there was no statistical difference in mean oxygen tensions between the two anaesthesia groups. The trial was excluded due to the lack of outcome data for the anaesthesia comparison.

El-Zahaar 1995This study was a randomised comparison of general versus epidural anaesthesia in 214 patients undergoing either hip or femoral surgery (117 patients), or tibial surgery (97 patients). This trial was excluded because separate results for patients having surgery for a hip fracture were not presented.

Favarel 1996A randomised trial of 60 hip fracture patients comparing the haemodynamic effects of a single dose of spinal bupivacaine versus a continuous titrated dose. Outcome measures were the onset of anaesthesia and haemodynamic variables. The trial was excluded as it was not considered a comparison of different forms of anaesthesia, only of a modification of anaesthetic technique.

Hemmingsen 1991A trial of 30 patients having osteosynthesis of a hip fracture under spinal anaesthesia. They were randomised to receive either ketamine or fentanyl intravenously during the procedure. The trial was excluded as it was not a trial of different types of anaesthesia but a comparison of different drugs within one form of anaesthesia.

Marhofer 1999This randomised trial of 24 hip fracture patients compared 500 ml of intravenous hetastarch with 1500 ml of lactated Ringer's solution given preoperatively. All patients received spinal anaesthesia. The study was excluded as it was not a comparison of anaesthetic methods.

Matot 2003This study involved 68 patients with hip fractures who either had known coronary artery disease or were at high risk for coronary artery disease. Patients were randomised to receive a 'usual' care analgesic regimen or intramuscular meperidine, or continuous epidural infusion of local anaesthetic and opiate. The study was excluded as it compared techniques outside the scope of this review.

Maurette 1993A randomised trial of 34 hip fracture patients comparing continuous spinal anaesthesia with lidocaine alone versus lidocaine with meperidine. The trial was excluded as it was a trial of different drugs with the same anaesthetic technique, not a comparison of different types of anaesthesia.

Naja 2000This trial compared 30 patients who selected general anaesthesia with 30 who selected a nerve stimulator guided combined sciatic-paravertebral nerve block. All patients had hip fracture surgery. The study was excluded as there was no randomisation of patients.

Nishikawa 2002This was a trial of 90 patients having hip fracture surgery under spinal anaesthesia. Patients were randomised to receive intramuscular phenylephrine or saline. It was excluded as it was not a comparison of different types of anaesthesia.

Owen 1982A randomised trial of a single dose of doxapram on the post-operative arterial oxygen tension in hip fracture patients. The trial was excluded as it was not a comparison of anaesthetic techniques.

Sinclair 1997A randomised trial of 40 patients with a hip fracture surgically treated under general anaesthesia. Patients were randomised to have either conventional intra-operative fluid management or colloid fluid challenges. The study was excluded as it was not a comparison of different types of anaesthesia.

Sutcliffe 1994A comparative study of 1333 patients with general versus spinal anaesthesia. The study was excluded as there was no randomisation of patients.

Tonczar 1981A randomised trial of 14 patients comparing neuroleptic anaesthesia with spinal anaesthesia. The study was excluded as it involved a neuroleptic anaesthesia and the only outcome measures were plasma catecholamines, cortisol, blood pressure and changes in heart rate.

Ungemach 1987A randomised trial of 50 hip fracture patients using either enflurane or enflurane and fentanyl. The trial was excluded as it was a comparison of different drugs within one type of anaesthesia (general anaesthesia) and not a comparison of different anaesthetic techniques.

Van Gessel 1989A randomised trial of 30 hip fracture patients comparing spinal anaesthesia with either hypobaric tetracaine or hypobaric bupivacaine. The trial was excluded as it was a not a trial of different types of anaesthesia but a comparison of different drugs within one form of anaesthesia.

Wickstrom 1982This was a report of two quasi-randomised trials (based on dates of birth) with a month in-between, reported as one study. The first study compared epidural versus ketamine intravenous infusion versus neurolept general anaesthesia in 129 hip fracture patients. The second study compared enflurane general anaesthesia versus halothane general anaesthesia in 40 hip fracture patients. The first study was excluded as it was considered that neuroleptic anaesthesia was no longer applicable or relevant for hip fracture surgery. A comparison of non-concurrent treatment groups was also not considered appropriate. The second study was excluded as it was a comparison of different drugs within one type of anaesthesia (general anaesthesia) and not a comparison of different anaesthetic techniques.

 
Comparison 1. Regional (spinal or epidural) versus general anaesthesia

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mortality - 1 month81668Risk Ratio (M-H, Fixed, 95% CI)0.69 [0.50, 0.95]

 2 Mortality - 1 month (random effects model)81668Risk Ratio (M-H, Random, 95% CI)0.68 [0.44, 1.05]

 3 Mortality - 3 months61491Risk Ratio (M-H, Fixed, 95% CI)0.92 [0.71, 1.21]

 4 Mortality - 6 months31264Risk Ratio (M-H, Fixed, 95% CI)1.04 [0.81, 1.33]

 5 Mortality - 12 months2726Risk Ratio (M-H, Fixed, 95% CI)1.07 [0.82, 1.41]

 6 Mortality - early and up to 1 month111878Risk Ratio (M-H, Fixed, 95% CI)0.73 [0.54, 0.99]

 7 Length of operation (mins)8446Mean Difference (IV, Random, 95% CI)0.76 [-5.37, 6.90]

 8 Operative hypotension111022Risk Ratio (M-H, Fixed, 95% CI)1.30 [1.08, 1.55]

 9 Operative hypotension (random effects model)111022Risk Ratio (M-H, Random, 95% CI)1.10 [0.79, 1.55]

 10 Operative blood loss (ml)5378Mean Difference (IV, Random, 95% CI)-85.28 [-161.95, -8.61]

 11 Patients receiving blood transfusion4258Risk Ratio (M-H, Fixed, 95% CI)0.95 [0.77, 1.17]

 12 Transfusion requirements (ml)4243Mean Difference (IV, Random, 95% CI)99.75 [-52.99, 252.48]

 13 Postoperative hypoxia2117Risk Ratio (M-H, Fixed, 95% CI)0.67 [0.36, 1.22]

 14 Length of hospital stay2218Mean Difference (IV, Fixed, 95% CI)-0.21 [-5.21, 4.78]

 15 Pneumonia91186Risk Ratio (M-H, Fixed, 95% CI)0.76 [0.44, 1.30]

    15.1 Fatal (reason for death only)
61019Risk Ratio (M-H, Fixed, 95% CI)1.00 [0.52, 1.94]

    15.2 Other (non fatal or fatal)
3167Risk Ratio (M-H, Fixed, 95% CI)0.42 [0.16, 1.13]

 16 Myocardial infarction61033Risk Ratio (M-H, Fixed, 95% CI)0.55 [0.22, 1.37]

    16.1 Fatal (reason for death only)
4934Risk Ratio (M-H, Fixed, 95% CI)0.44 [0.13, 1.50]

    16.2 Other (non fatal or fatal)
299Risk Ratio (M-H, Fixed, 95% CI)0.76 [0.20, 2.96]

 17 Cerebrovascular accident71085Risk Ratio (M-H, Fixed, 95% CI)1.51 [0.64, 3.57]

    17.1 Fatal (reason for death only)
4856Risk Ratio (M-H, Fixed, 95% CI)1.22 [0.40, 3.71]

    17.2 Other (non fatal or fatal)
3229Risk Ratio (M-H, Fixed, 95% CI)2.07 [0.53, 8.06]

 18 Congestive cardiac failure7931Risk Ratio (M-H, Fixed, 95% CI)1.05 [0.49, 2.23]

    18.1 Fatal (reason for death only)
3623Risk Ratio (M-H, Fixed, 95% CI)1.34 [0.44, 4.10]

    18.2 Other (non fatal or fatal)
4308Risk Ratio (M-H, Fixed, 95% CI)0.85 [0.30, 2.40]

 19 Renal failure5912Risk Ratio (M-H, Fixed, 95% CI)0.76 [0.23, 2.49]

    19.1 Fatal (reason for death only)
3724Risk Ratio (M-H, Fixed, 95% CI)0.79 [0.18, 3.46]

    19.2 Other (non fatal or fatal)
2188Risk Ratio (M-H, Fixed, 95% CI)0.72 [0.10, 5.13]

 20 Acute confusional state5237Risk Ratio (M-H, Fixed, 95% CI)0.50 [0.26, 0.95]

 21 Urine retention297Risk Ratio (M-H, Fixed, 95% CI)1.02 [0.47, 2.23]

 22 Vomiting295Risk Ratio (M-H, Fixed, 95% CI)0.70 [0.12, 3.94]

 23 Deep vein thrombosis4259Risk Ratio (M-H, Fixed, 95% CI)0.64 [0.48, 0.86]

    23.1 Fatal (underlying reason for death only)
155Risk Ratio (M-H, Fixed, 95% CI)0.22 [0.01, 4.43]

    23.2 Other: venography diagnosis
2128Risk Ratio (M-H, Fixed, 95% CI)0.72 [0.47, 1.11]

    23.3 Other: fibrinogen scan diagnosis
176Risk Ratio (M-H, Fixed, 95% CI)0.60 [0.40, 0.88]

 24 Pulmonary embolism (Peto odds ratio plot - showing heterogeneity)91245Peto Odds Ratio (Peto, Fixed, 95% CI)0.72 [0.31, 1.69]

 25 Pulmonary embolism (random effects model)91245Risk Ratio (M-H, Random, 95% CI)0.88 [0.32, 2.39]

 26 Pulmonary embolism (fatal and non-fatal)9Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    26.1 Fatal (reason for death only)
61030Risk Ratio (M-H, Fixed, 95% CI)0.43 [0.17, 1.10]

    26.2 Non fatal
4255Risk Ratio (M-H, Fixed, 95% CI)3.46 [0.74, 16.29]

 
Comparison 2. Spinal and 'light' general anaesthetic versus general anaesthetic

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mortality - 1 month1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Length of operation1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Pneumonia1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Confusional state1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Deep vein thrombosis1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 3. Regional (spinal or epidural) versus lumbar plexus nerve blocks

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Incomplete or unsatisfactory analgesia279Risk Ratio (M-H, Fixed, 95% CI)0.23 [0.10, 0.50]

    1.1 Regional (spinal) block versus lumbar plexus block
150Risk Ratio (M-H, Fixed, 95% CI)0.26 [0.12, 0.59]

    1.2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block
129Risk Ratio (M-H, Fixed, 95% CI)0.10 [0.01, 1.61]

 2 Operative hypotension1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Regional (spinal) block versus lumbar plexus block
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Mean fall in arterial blood pressure (mmHg)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Mean dose of ephedrine used (mg)279Mean Difference (IV, Fixed, 95% CI)5.96 [4.46, 7.45]

    4.1 Regional (spinal) block versus lumbar plexus block
150Mean Difference (IV, Fixed, 95% CI)5.8 [4.28, 7.32]

    4.2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block
129Mean Difference (IV, Fixed, 95% CI)10.0 [2.24, 17.76]

 5 Adverse effects2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    5.1 Regional (spinal) block versus lumbar plexus block
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Postoperative confusion1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    6.2 Regional (spinal) block versus lumbar plexus, sacral and iliac crest block
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 4. Intravenous ketamine versus general anaesthesia

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mortality - during hospital stay1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Myocardial infarction1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Congestive cardiac failure1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Pulmonary embolism1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Length of hospital stay (discharge home)1Mean Difference (IV, Fixed, 95% CI)Totals not selected