General Anesthesia Versus Intraspinal Anesthesia In Elderly Patients Undergoing Total Hip Or Knee Replacement:A Systematic Review

ObjectiveElderly patients undergoing total hip or knee replacement often use general anesthesia and intraspinal anesthesia, but the effect of two kinds of anesthesia on perioperative patients is still controversial. To carry out a meta-analysis using of the Cochrane system evaluation method to evaluate the perioperative complications of general anesthesia versus intraspinal anesthesia in elderly patients undergoing total hip or knee replacement.Methods Databases including The Cochrane Library (Issue2,2014), the database of the Cochrane Anesthesia Group, MEDLINE, EMbase, PubMed, Ovid, Springer, CBM, CNKI, VIP and Wanfang Data were electronically searched from inception to February2014for the randomized controlled trials (RCT) of general anesthesia versus intraspinal anesthesia in elderly patients undergoing total hip or knee replacement. Two reviewers independently screened literature according to the inclusion and exclusion criteria, extracted date, and assessed the quality of included studies. Then, meta-analysis was performed using RevMan5.1software.Results14trials involving1,197patients were included, of which,608received general anesthesia and589received intraspinal anesthesia. The results of meta-analyses showed that:a) Deep vein thrombosis (DVT):The incidence of DVT was31.8%(70/220) in the general anesthesia group,19.0%(40/211) in the intraspinal anesthesia group. Compared with general anesthesia, intraspinal anesthesia was superior for reducing the incidence of DVT (OR=2.22,95%CI1.35to3.63, P=0.002).b) Pulmonary embolism (PE):The incidence of PE was7.4%(15/204) in the general anesthesia group,3.5%(7/202) in the intraspinal anesthesia group. There were no significant differences in the incidence of PE (OR=2.14,95%CI0.88to5.19, P=0.09) between the two groups.c) Short-term post-operative cognitive dysfunction (short-term POCD) and long-term post-operative cognitive dysfunction (long-term POCD):The incidence of short-term POCD was58.9%(53/90) in the general anesthesia group,40.0%(36/90) in the intraspinal anesthesia group. Compared with intraspinal anesthesia, general anesthesia was superior for increasing the incidence of short-term POCD (OR=2.40,95%CI1.26to4.57, P=0.008). The incidence of long-term POCD was19.4%(20/103) in the general anesthesia group,11.7%(12/103) in the intraspinal anesthesia group. There were no significant differences in the incidence of long-term POCD (OR=2.67,95%CI0.33to21.57, P=0.36) between the two groups.d) lntra-operative blood losse and intra-operative transfusions:There were no significant differences in the intra-operative blood losses (SMD=159.58,95%CI-98.95to418.10, P=0.23) between the two groups. The incidence of intra-operative transfusions was32.3%(113/350) in the general anesthesia group,14.4%(47/326) in the intraspinal anesthesia group. Compared with general anesthesia, intraspinal anesthesia was superior for reducing the incidence of intra-operative transfusions (OR=3.42,95%CI1.67to7.13, P=0.001) between the two groups.e) Post-operative blood losses and post-operative transfusions:The incidence of post-operative transfusions was18.0%(14/78) in the general anesthesia group,28.4%(19/67) in the intraspinal anesthesia group. There were no significant differences in the post-operative blood losses (SMD=54.97,95%CI-26.52to136.45, P=0.19) and the incidence of post-operative transfusions (OR=1.13,95%CI0.02to71.97, P=0.95). f) Duration of surgery:Compared with general anesthesia, intraspinal anesthesia was superior for reducing the duration of surgery (SMD=7.78,95%CI3.23to12.33, P=0.0008).g) Secondary outcomes:The incidence of pneumonia, PONV and mortality during hospitalization was respectively1.9%(2/103),32.3%(113/350) and2.9%(3/103) in the general anesthesia group,2.9%(3/106),14.4%(47/326) and1.0%(1/103) in the intraspinal anesthesia group.Compared with general anesthesia, intraspinal anesthesia was superior for reducing the incidence of PONV (OR=2.73,95%CI1.20to6.21, P=0.02). There were no significant differences in the incidence of pneumonia (OR=0.65,95%CI0.11to4.00, p=0.64) and the mortality during hospitalization [OR=2.36,95%CI0.34to16.35,p=0.38) between the two groups.Conclusion A total of14trials involving1197participants were included. Meta-analyses used of the Cochrane system evaluation method showed that:a) Compared with general anesthesia, intraspinal anesthesia was superior for reducing the incidence of DVT. There were no significant differences in the incidence of PE in elderly patients undergoing total hip or knee replacement between the two groups.b) Compared with intraspinal anesthesia, general anesthesia increased the incidence of short-term POCD. There were no significant differences in the incidence of long-term POCD between the two groups.c) Compared with intraspinal anesthesia, general anesthesia increased the incidence of intra-operative transfusions. There were no significant differences in the intra-operative blood losses, post-operative blood losses and incidence of post-operative transfusions.d) Intraspinal anesthesia reduced the duration of surgery and the incidence of PONV. There were no significant differences in the incidence of pneumonia and the mortality during hospitalization between the two groups.However, the above conclusion should be verified by conducting more high quality randomized controlled trials.