Neuraxial anaesthesia for lower-limb revascularization

Background Lower-limb revascularization surgery is used to reduce pain and sometimes to improve lower-limb function. The type of anaesthesia used during lower-limb revascularization may affect the risks of both good and bad outcomes. Objectives To determine the rates of death and major complications with spinal and epidural anaesthesia compared with other types of anaesthesia for lower-limb revascularization. Search strategy We searched CENTRAL (The Cochrane Library 2008, Issue 2); MEDLINE (1960 to 10th June 2008); EMBASE (1982 to 10th June 2008); LILACS (1982 to 10th June 2008); CINAHL (1982 to 10th June 2008) and ISI Web of Science (1900 to 10th June 2008). Selection criteria We included randomized controlled trials that evaluated the effect of anaesthetic type in adults aged 18 years or older undergoing lower-limb revascularization surgery. Data collection and analysis Two authors independently performed the data extraction. Primary outcomes were mortality, cerebral stroke, myocardial infarction, nerve dysfunction and postoperative lower-limb amputation rate. The secondary outcome analysed was pneumonia. We judged risk of bias with four criteria: randomization and allocation concealment methods, blinding of treatment and outcome assessment and completeness of follow up. To assess heterogeneity we used the I-2 statistic. We summarized dichotomous data as odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. Main results We included four studies that compared neuraxial anaesthesia with general anaesthesia. The total number of participants was 696, of whom 417 were allocated to neuraxial anaesthesia and 279 to general anaesthesia. Participants allocated to neuraxial anaesthesia had a mean age of 67 years and 59% were men. Participants allocated to general anaesthesia had a mean age of 67 years and 66% were men. There was no difference between participants allocated to neuraxial or general anaesthesia in: mortality rate (OR 0.89, 95% CI 0.38 to 2.07; 696 participants, four trials); myocardial infarction (OR 1.23, 95% CI 0.56 to 2.70; 696 participants, four trials); and lowerlimb amputation rate (OR 0.84, 95% CI 0.38 to 1.84; 465 participants, three trials). Pneumonia was less common following neuraxial anaesthesia than general anaesthesia (OR 0.37, 95% CI 0.15 to 0.89; 201 participants, two trials). Authors' conclusions There was insufficient evidence available from the included trials that compared neuraxial anaesthesia with general anaesthesia to rule out clinically important differences for most clinical outcomes. Neuraxial anaesthesia may reduce pneumonia. No conclusions can be drawn with regard to mortality, myocardial infarction and rate of lower-limb amputation or less common outcomes.