Evidence Table 65Regional vs general anaesthesia

Bibliographic referenceStudy TypeEvidence levelNo. of patientsPatients characteristicsInterventionComparisonLength of follow upOutcome measuresEffect sizeComments
Mitchell et al., 1991454RCT1+Total: 72
Intervention : n = 34
Control: n = 38
Type of surgery: total knee arthroplasty
Duration of surgery:
Intervention : mean 122 min Control: mean 121 min

Both study groups:
Mean age: 64 (range38–84) yrs
M/F:45/27
No between-group differences for age or sex
Type: Epidural anaesthesia Dose:

Timing: Operative period

Additional noncomparative prophylaxis: Males received 650mg aspirin beginning eve pre-surgery, females received adjusted dose warfarin PTT 15–16 secs. All patients CPM machine daily and physical therapy
Type: General anaesthesia
Dose: sodium theopental

Timing:
Operative period

Additional noncomparative prophylaxis:
Males received 650mg aspirin beginning eve pre-surgery, females received adjusted dose warfarin PTT 15–16 secs. All patients CPM machine daily and physical therapy
Scan performed up to day 8 after surgeryDVT Confirmed by: bilateral venography 6,7 and 8th post-op daysInt: 12/34
Control: 10/38
p value: Not significant
All asymtomatic
Comments: Male patients received aspirin, female warfarin. No differences in sex between study groups, and incidence and distribution of DVT not affected by pharmacological prophylaxis.

Not reported: PTS, bleeding, QoL, survival, funding
Proximal DVT
Confirmed by:
Incidence of Proximal DVT reported to be 46% in epidural and 63% in general anaesthesia groups. (actual numbers can’t be reliably calculated from these figures)
PE Confirmed by: V/Q scan on 6,7 and 8th postop days10% of patients reported as having positive V/Q scan, all asymptomatic.
No information on group.
Length of Hospital StayInt: Mean 10.4 days Control:
Mean 11.0 days
p value: not reported
Modig et al., 1981456RCT1+Total: 30
Intervention: n = 15
Control: n = 15
Type of surgery:
Total hip replacement (for severe osteoarthritis)
Duration of surgery:
Intervention:
147±27.9min
Control:
161.3±34.5 min

Intervention: Mean age: 66.5±5.5 yrs
M/F:7/8

Control: Mean age:
65.4±6.3 M/F:8/7
Type: Continuous lumbar epidural block
Dose: 0.5% bupivacaine with epinephrine (5μg/ml)

Post op: 4–6 ml of 0.5% bupivacaine with epinephrine ever 4 hours for 16 hours

Timing: Prolonged into post-op period for pain relief

Additional noncomparative prophylaxis:
Physiotherapy program with early ambulation
Type: General anaesthesia
Dose: thiopentone

Post-op:
Parenteral analgesics on demand

Timing:
Intraoperatively.

Additional noncomparative prophylaxis:
Physiotherapy program with early ambulation
Scanning was performed 14 days before surgery and 14 days postoperativelyDVT Confirmed by: Bilateral venography on 14th post-op dayInt: 5/15
Control: 11/15
p value: 0.0281
Not reported: PTS, QoL, survival, LoS, funding
Proximal DVT
Confirmed by:
Int: 3/15
Control: 11/15
p value: <0.05
PE Confirmed by: all patients had V/Q scan on 14th post-op dayInt: 2/15
Control: 7/15
p value: Not significant

Only 3 PEs (all in control group) were symptomatic
Bleeding related complications

Intraoperative blood loss: (no measurement criteria)

Post-operative blood loss: (no measurement criteria)
Intraoperative blood loss:
Int: 1100±316 ml
Control:
1757±426ml p value: <0.001
(Significant)

Postoperative blood loss:
Int: 1200±350 ml
Control: 1800±400 ml p value: <0.001
(Significant)
Nielsen et al., 1990488RCT1+Nos randomised:
Total: 36
Intervention: n = 18
Control: n = 18

7 patients withdrawn – 5 epidural, 2 general
Type of surgery: primary or revision knee arthroscopy
Duration of surgery:
Intervention: median 80 (55–100) min
Control: min

Intervention:
Median age: 70 (range 46–87) yrs
M/F:5/13

Control: Median age: 65 (range 38–85) M/F:6/12

Pre-existing risk factors: Cardiac disease, varicose veins. Higher BMI in control group
Type: lumbar epidural anaesthesia Dose: 2% mepivacain

Additional noncomparative prophylaxis: Thighlength stocking on contralateral leg preop until full ambulation. Calflength stocking on operated leg immediately post-op until ambulation. Quad exercises on 1st postop day, active knee mobilisation with full weight bearing from 2nd day.
Type: general anaesthesia
Dose:

Additional noncomparative prophylaxis:
Thigh-length stocking on contralateral leg pre-op until full ambulation. Calflength stocking on operated leg immediately postop until ambulation. Quad exercises on 1st post-op day, active knee mobilisation with full weight bearing from 2nd day.
Both groups: 9–11 days post-opDVT Confirmed by: bilateral ascending venography on 9–11th day post-opInt: 2/13
Control: 10/16
p value: <0.05
Not reported: PTS, PE, QoL, survival, LoS, funding
Proximal DVT
Confirmed by: bilateral ascending venography on 9–11th day post-op
Int: 1/13
Control: 3/16
p value: Not reported
Bleeding related complications
Suction drain volume
Median suction drain volume:
Int: 1060 (340–1940) ml
Control: 990 (195–3275)
p value: >0.4 Not significant
Poikolainen and Hendolin 1983529RCT1+Total: 38
Intervention: n = 17
Control: n = 21
Type of surgery:
Prostatectomy
Duration of surgery:
Intervention: 71±3 min Control: 74±3 min

Intervention: All male
Mean age: NR. No differences between groups for age

Control: All male
Mean age: NR. No differences between groups for age

Pre-existing risk factors: NR. No differences between groups
Type: lumbar epidural anaesthesia Dose: Butanilicaine 2%

Additional noncomparative prophylaxis: Not reported
Type: General anaesthesia
Dose: Thiopentone
NRDVT Confirmed by: 125I FUT test (timing NR).
Positive result confirmed by venography
Int: 2/17
Control: 11/21
p value: <0.02
(Significant)
Comments: Study measured changes in flow velocity in femoral vein.
Induction of epidural anaesthesia led to significant increase in velocity of blood flow in femoral vein (p<0.001), whereas flow velocity fell significantly with general anaesthesia.
Roderick et al., 2005

11 RCT studies81,146,147,197,275,276,315, 438,455,558,696

All of these studies were included in the guideline review.
Systematic Review1+Total: 939
Int:367
Cont: 384

Misc: 188 (not reported number in each arm)
Type of surgery:
General (1 study)
Urological (1 study)
Orthopaedic (9 studies)
Regional Anaesthesia

Timing: Ranged from 73 mins to 3 days

Not addressed in 4 studies

Additional non-comparative prophylaxis:
LMWH + GCS (one study); GCS (two studies); Dextran 70 (one study); Dextran 40 + 7500 IU H (one study); ASA, GCS on no-op limb (one study).
General Anaesthesia

Timing: Ranged from 79 – 150 mins.

Not addressed in 6 studies.

Additional non-comparative prophylaxis:
LMWH + GCS (one study); GCS (two studies); Dextran 70 (one study); Dextran 40 + 7500 IU H (one study); ASA, GCS on no-op limb (one study).
Between 4 to 14 days postoperativelyDVT confirmed by venograph or fibrinogen uptakeInt : 130/417
Cont: 198/416
p value: 0.0000
Not reported: LoS, QoL and PTS.
PE confirmed by scanInt : 21/281
Cont: 32/264 (reported in 6 studies)
p value: 0.0672
Major bleedsInt : 0/317
Cont: 5/315 (reported in 7 studies)
p value: 0.0243
Proximal DVTsInt : 14/268
Cont: 47/253 (reported in 6 studies)
p value: 0.0000

From: Appendix D, Evidence tables

Cover of Venous Thromboembolism
Venous Thromboembolism: Reducing the Risk of Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to Hospital.
NICE Clinical Guidelines, No. 92.
National Clinical Guideline Centre – Acute and Chronic Conditions (UK).
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