General versus spinal/epidural anaesthesia for surgery for hip fractures in adults.

BACKGROUND: The majority of hip fracture patients are treated surgically, requiring anaesthesia. OBJECTIVES: To compare different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults. This is primarily regional (spinal or epidural) anaesthesia versus inhalation general anaesthesia, but also includes ketamine anaesthesia versus inhalation general anaesthesia. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, selected orthopaedic and anaesthetic journals and conference proceedings, and reference lists of relevant articles. Date of the most recent search: August 1998. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing different methods of anaesthesia for hip fracture surgery in skeletally mature persons. Trials comparing the use of local nerve blocks are not considered in this review. Neither are trials using different types of drugs or techniques with one type of anaesthesia. The primary outcome was mortality. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, using a nine item scale, and extracted data. The other two reviewers independently checked these results. Wherever appropriate and possible, results were pooled. MAIN RESULTS: Fifteen trials, involving 2162 patients, which compared regional anaesthesia with general anaesthesia, were included. All trials had methodological flaws. Regional anaesthesia was associated with a decreased mortality at one month (49/766 (6.4%) versus 76/812 (9.4%)) of borderline statistical significance (Peto odds ratio 0.66, 95% confidence interval 0.46 to 0.96)). The results for three month mortality were not statistically significant, although the confidence interval does not exclude the possibility of a clinically relevant reduction (86/726 (11.8%) versus 98/765 (12.8%), Peto odds ratio 0.91, 95% confidence interval 0.67 to 1.24). The reduced numbers at one year, coming exclusively from two studies, preclude any useful conclusions for long term mortality (80/354 (22.6%) versus 78/372 (21.0%), Peto odds ratio 1.10, 95% confidence interval 0.77 to 1.57). Regional anaesthesia was associated with a tendency to a longer operation (weighted mean difference 4.8 minutes, 95% confidence interval 1.1 to 8.6 minutes), and a reduced risk of deep venous thrombosis (39/129 (30%) versus 61/37(76%); Peto odds ratio 0. 41, 95% confidence interval 0.23 to 0.72), although this conclusion is insecure due to possible selection bias in the subgroups in whom this outcome was measured. No other statistically significant differences in outcome were identified. There was insufficient evidence to draw any conclusions from a further two included trials, involving a total of 100 patients, which compared other types of anaesthesia. REVIEWER'S CONCLUSIONS: Regional anaesthesia and general anaesthesia appear to produce comparable results for most of the outcomes studied. Regional anaesthesia may reduce short-term mortality but no conclusions can be drawn for longer term mortality.

General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials.

Hip fracture surgery is common and the population at risk is generally elderly. There is no consensus of opinion regarding the safest form of anaesthesia for these patients. We performed a meta-analysis of 15 randomized trials that compare morbidity and mortality associated with general or regional anaesthesia for hip fracture patients. There was a reduced 1-month mortality and incidence of deep vein thrombosis in the regional anaesthesia group. Operations performed under general anaesthesia had a reduction in operation time. No other outcome measures reached a statistically significant difference. There was a tendency towards a lower incidence of myocardial infarction, confusion and postoperative hypoxia in the regional anaesthetic group, and cerebrovascular accident and intra-operative hypotension in the general anaesthetic group. We conclude that there are marginal advantages for regional anaesthesia compared to general anaesthesia for hip fracture patients in terms of early mortality and risk of deep vein thrombosis.

Prognostic indicators following emergency aortic aneurysm repair.

We performed a retrospective study of 135 patients presenting for emergency abdominal aneurysm repair to determine predictive factors for outcome. The outcome measures investigated were mortality in the operating theatre and intensive care, and at 28 and 100 days. Univariate analysis showed that the patient's age, hypotension on admission, aneurysmal rupture, pre-operative cardiopulmonary resuscitation, intra-operative blood loss and hypotension were risk factors for death either in the operating theatre or up to 100 days after surgery. Binary logistic regression identified the independent risk factors for survival. Operative survival was determined by acute factors such as pre-operative cardiopulmonary resuscitation, aneurysmal rupture and intra-operative hypotension. Longer term survival was determined by the patient's age, aneurysmal rupture, blood loss and blood pressure at admission. Using a binary logistic regression equation, from which a simplified risk score was derived, it is possible to predict the likelihood of survival of individual patients presenting for abdominal aortic aneurysm repair.

Fatal nefopam overdose.

Nefopam is a non-opioid analgesic agent with a central mode of action involving activation of descending pain-modulating pathways and inhibition of synaptosomal uptake of hydroxytryptamine, norepinephrine and dopamine. Adverse effects during therapeutic use and after overdose of nefopam are known to involve the central nervous system (confusion and convulsions), the cardiovascular system (tachycardia and palpitations) and the kidneys (oliguria and renal failure). We report a death after nefopam overdose in a young woman who exhibited many of these features. It is only the second case of death after nefopam overdose in the literature.

Preschool language intervention--a follow-up of some within-group differences.

A more detailed study was made of the children who had been followed-up by Urwin, Cook & Kelly (1988) 4-8 years after leaving a preschool language group. Children were independently allocated into groups according to their speech and language diagnosis prior to entry to the Unit. There were two major dimensions--receptive/expressive versus expressive only, and phonology versus non-phonology. Comparisons were made between the group as indicated by children's performance at follow-up for measures of ability, achievement, language and social functioning. Conclusions are drawn about the long-term effects of the early language difficulty and preschool intervention. Attention is also drawn to differences in perceiving the effects of language difficulty between the specialist professionals on the one hand and parents and teachers on the other.

The effect of the selective PAF antagonist BN 52021 on PAF- and antigen-induced bronchial hyper-reactivity and eosinophil accumulation.

Sensitised guinea-pigs were exposed to an aerosol of ovalbumin (100-500 micrograms/ml) and normal animals were exposed to an aerosol of platelet activating factor (PAF) (250-1000 micrograms/ml). Twenty-four hours later, bronchial reactivity was assessed by measurement of air overflow in response to i.v. histamine or acetylcholine using the Konsett-Rossler technique. Additionally, bronchoalveolar lavage was performed by washing the lungs with 10 ml of 0.9% saline and differential counts obtained to assess the ability of PAF and antigen to elicit pulmonary inflammatory cell recruitment. Both PAF and antigen exposure produced a dose-related increase in bronchial reactivity, while treatment with the vehicle (either 0.25% bovine serum albumin or 0.9% saline) had no effect on airway responsiveness. Furthermore, both PAF and antigen exposure produced a selective accumulation of eosinophils into the airways. There was no significant change in the number of neutrophils, macrophages or lymphocytes. The selective PAF antagonist BN52021 inhibited both the development of bronchial hyper-reactivity and the eosinophil influx into the airways induced by PAF or antigen exposure. These observations suggest that PAF has a central role to play in the antigen induced eosinophil accumulation and subsequent bronchial hyper-reactivity.

Preschool language intervention: a follow-up study.

A follow-up study was undertaken of 38 children who had attended a preschool language unit with detailed assessments of 25 by speech therapists and an educational psychologist. The subjects were assessed in a number of areas (language, learning and social skills) using standardized tests and rating schedules completed by teachers and parents. The initial results are presented in terms of group characteristics. At a mean age of 8.3 years the children were still making progress in all areas of development. Although some 16% of the children were attending specialist schools or classes (language unit, physically handicapped unit, schools for children with severe speech and language problems), the majority (84%) were within the mainstream of education. A continuing language difficulty was apparent on standardized tests. Reading and spelling were slightly depressed, but not significantly so. However, parents and teachers saw the children as differing little from their peers. The conclusion is reached that preschool intervention can prevent later educational failure.