Background
Methods
Protocol and registration
Eligibility criteria
Information sources and search
Study selection and data collection
Data items
Assessment of risk of bias
Statistics
Results
Study selection
Study characteristics/participants
Author/Reference | Study type | Anaesthesia | Sample size | Primary outcome | Secondary outcome | Results | Conclusion |
---|---|---|---|---|---|---|---|
Basques et al. 2015 [8] | Retrospective observational study | GA vs. SA |
n = 9.842 GA = 7.253 (73.7%) SA = 2.589 (26.3%) | Operating time; length of stay (LOS); adverse events within 30 post-operative days, rate of re-admission | 30-day mortality | 30- day mortality: GA vs. SA: (OR 0.98, 95% CI 0.82 to 1.20, p = 0.908); LOS: GA vs SA: (HR: 1.28, 95% CI 1.22 to 1.34, p < 0.001) | There was no difference between the groups except of length of hospital stay. |
Biboulet et al. 2012 [32] | Randomised controlled study | GA vs. SA (propofol, sevoflurane) |
n = 45 GA = 30 SA = 15 | Blood pressure profile, heart rate profile | 30-day mortality | Hypotension episodes: SA = 0 (range, 0-6) vs. propofol = 11.5 (range 1-25) vs. sevoflurane = 10 (range,1-23) (p < 0.0001); maximal decrease in arterial pressure: SA = 26% [16], propofol = 47% [8%], sevoflurane = 46% [12%] (p < 0.001) | SA in elderly patients provided better blood pressure stability than propofol and sevoflurane. |
Brox et al. 2016 [23] | Retrospective observational study | GA vs. SA vs. mixed |
n = 7.585 GA = 4.257 (56%) SA = 3.059 (40%) Mixed = 269 (4%) | 30-day, 90-day and 365-day mortality | 30-day mortality: GA = 177 (4%) vs. SA = 113 (4%) vs. mixed = 17 (6%); 90-day mortality: GA = 336 (8%) vs. SA = 224 (7%) vs. mixed = 23 (9%); 365-day mortality: GA = 661 (16%) vs. SA = 424 (14%) vs. mixed = 41 (15%) | There was no difference between the groups. | |
Chu et al. 2015 [25] | Retrospective observational study | GA vs. NA (spinal/epidural) |
n = 104.088 GA = 52.044 NA = 52.044 | In-hospital mortality | Acute stroke, transient ischemic stroke, acute myocardial infarction, acute respiratory failure, acute renal failure | In-hospital death: GA vs. NA: 1.363 (2.62%) vs. 1.107 (2.13%), p < 0.001 | The GA group had a greater percentage and higher odds of adverse in-hospital events than the NA group. |
Fields et al. 2010 [9] | Retrospective observational study | GA vs. SA |
n = 6.133 GA = 4.318 (72.6%) SA = 1.815 (27.4%) | 30-day complications, 30-day mortality | none | SA vs. GA: 30-day mortality: (6.67 vs. 5.84, p = 0.21); overall complications: (45.75% vs. 48.97%, p = 0.001) | GA had a higher risk of 30-day complications compared to SA. There was no difference related to mortality. |
Heidari et al. 2011 [33] | Randomised controlled study | GA vs. NA (EA/SA) |
n = 270 GA = 197 NA = 190 | 30-day mortality, in-hospital mortality, Length of hospital stay, postoperative complications | None | 30-day mortality: GA vs. NA: 0 vs. 2, p = 0.299; In-hospital mortality: GA vs. NA: 5 vs. 0, p = 0.107; Length of hospital stay: GA vs. NA: 4.3 (1.8) vs. 3.8 (1.6), p = 0.042 | The length of hospital stay was significantly longer in the GA group. The morbidity and mortality rates were similar in both groups. |
Helwani et al. n [10] | Retrospective observational study | GA vs.NA (SA/EA) |
n = 12.929 GA = 7.826 (60.5%) NA = 5.103 (39.5%) [SA = 4.377 (85.8%); EA = 126 (2.5%)] | 30-day mortality, LOS, deep surgical site infection (dssi), cardiovascular (cvc) -, pulmonary complications (pc) | None | NA vs. GA: dssi: (OR = 0.38; 95% CI = 3% to 7%; p < 0.001); LOS: (OR = 0.73; 95% CI = 0.68 to 0.89, p < 0.001); 30-day mortality: (OR = 0.78; 95% CI = 0.43 to 1.42; p > 0.05); cvc: (OR = 0.61; 95% CI = 0.44 to 0.85; p < 0.001); pc: (OR = 0.51; 95% CI = 0.33 to 0.81; p < 0.001) | NA was associated with a reduction in dssi rates, LOS, rates of postoperative cvc and pc. There was no difference in the mortality between NA and GA. |
Karademir et al. 2015 [11] | Retrospective observational study | GA vs. SA |
n = 11 GA = 30 (26%) SA = 85 (74%) | 1-year mortality rate | None | RA vs. GA: p = 0.63 | No significant difference in the 1-year mortality between GA and SA group |
Karaman et al. 2015 [12] | Retrospective observational study | GA vs. NA (SA/EA) |
n = 308 GA = 105 (34.1) NA = 203 (65.9%) | Overall-mortality | None | mortality rate: GA (n = 40) vs. NA (n = 37) (p < 0.01); OR: 2.761 (95% CI:1.62 to 4.69) | The mortality rate of patients receiving GA was higher than mortality rate of patients receiving NA. |
Kim et al. 2013 [13] | Retrospective observational study | GA vs. SA vs. EA |
n = 506 GA = 246 (48.62%) SA = 249 (49.21%) EA = 11 (2.17%) | 30-day mortality, pulmonary complications (pc); cardiac complications (cc); Delirium | None | 30-day mortality: GA = 7 (2.8%); SA = 4 (1.6%); EA = 0 (0.0%); p = 0.57; pc: GA = 91 (37.1%), SA = 74 (29.8%), EA = 3 (27.3%), p = 0.20; cc: GA = 4 (1.6%), SA = 2 (0.8%), EA = 0 (0.0%) p = 0.52; Delirium: GA = 31 (12.7%), SA = 27 (10.9%), EA = 1 (9.1%), p = 0.8 | Methods of anaesthesia did not influence mortality and postoperative complications. |
Le-Wendling et al. 2012 [14] | Retrospective observational study | GA vs. RA (single injection spinal, continuous spinal, continuous epidural) with or without continuous nerve block |
n = 308 GA = 235 (76.30%) RA = 73 (23.70%) | In-hospital mortality, hospitalization costs (hc), Length of stay (LOS) | Re-hospitalization | hc: RA vs. GA ($ 16.789 + 631 vs. $ 16.815 + 643, p = 0.9557); LOS: 6.4 vs. 6.6 days, p = 0.64; in-hospital mortality: 2 (2.74) vs. 9 (3.83) | There was no difference in postoperative morbidity, rates of re-hospitalization, in-patient mortality or hc in patients receiving RA or GA. |
Neuman et al. 2012 [27] | Retrospective observational study | GA vs. NA |
n = 18.158 GA = 12.904 NA = 5.254 | In-hospital mortality | Pulmonary and cardiovascular complications | In-hospital mortality: GA vs. NA: 325 (2.5%) vs. 110 (2.1%), p = 0.090 | The mortality rate was similar between the two groups. |
Neuman et al. 2014 [15] | Retrospective observational study | GA vs. NA (spinal/epidural) |
n = 56.729 GA = 40.825 (72%) NA = 15.904 (28%) | 30-day mortality | Length of stay (LOS) | 30-day mortality: NA = 5.3%, GA = 5.4% (difference 0.1%; 95 CI −0.5 to 0.3; p = 0.55); LOS: RA = 6 days (95% CI: 6 to 6.1) vs. GA = 6.3 days (95% CI: 6.2 vs. 6.3), difference LOS: −0.2 days (95% CI: −0.3 `to 0.2; p < 0.001) | 30-day mortality did not differ significantly between GA and NA. NA was associated with a shorter LOS. |
Parker et al. 2015 [31] | Randomised controlled study | GA vs. SA |
n = 322 GA = 164 (50.93%) SA = 158 (49.07%) | Mortality after 30, 90, 120 and 365 days | Surgical outcome, general complications, hospital stay (LOS) | 30-day mortality: GA vs SA (4.9% vs. 3.2%; p = 0.57); 90 days: (7.3% vs 7.6%; p = 1.00); 120 days: (7.3% vs 7.6%; p = 0.55); 365 days: (11.7% vs 20.2%; p = 0.05); LOS in days (standard deviation): GA = 15.9 (13.7); RA = 16.2 (14.6); p = 0.75 | No differences between GA and SA. |
Patorno et al. 2014 [16] | Retrospective observational study | GA vs NA (spinal/epidural) vs. GA + NA |
n = 73.284 GA = 61.554 (84.0%) NA = 6.939 (9.47%) GA + NA = 4.791 (6.53%) | In-hospital mortality | none | In-hospital mortality: GA vs. NA: (risk ratio 0.93, 95% CI 0.78 to 1.11) | Mortality risk did not differ significantly between GA and NA. |
Rashid et al. 2013 [17] | Retrospective observational study | GA vs. NA (epidural/spinal) |
n = 194 GA = 107 (55.15%) NA = 87 (44.85%) | Operating time, length of stay (LOS), blood loss, mortality | none | Operative time: GA = 1.54 ± 0.6, NA = 1.24 ± 0.39, p < 0.01; LOS: GA = 9.35 ± 9.0, NA = 8.63 ± 3.6, p = 0.484; blood loss: GA = 928 ± 360, NA = 912 ± 400, p = 0.758; mortality: GA = 4, NA = 5 | There were no differences between LOS, blood loss and mortality. The only significant difference was in the operating time. |
Shih et al. 2010 [18] | Retrospective observational study | GA vs. SA |
n = 335 GA = 167 (49.85%) SA = 168 (50.15%) | perioperative morbidity, duration of surgery, length of stay (LOS), blood loss | none | GA vs. SA: duration: 165 min. vs. 150 min.; p < 0.001, LOS: 9 days vs. 8 days, p = 0.04); overall mortality: (5/167 [3%] vs. 2/168 [1.2%]; p = 0.25); overall morbidity: (21/167 [12.6] vs. 9/168 [5.4%]; p = 0.02) | GA increased the risk of postoperative morbidity in octogenarian patients after hip fracture repair. Patients with pre-existing respiratory diseases were especially vulnerable. |
Seitz et al. 2014 [19] | Retrospective observational study | GA (inhalational, intravenous, GA combined with epidural or local anaesthesia) vs. SA |
n = 20.973 GA = 8.818 (42.1%) SA = 12.155 (57.9%) | 30-day mortality, 30-day postoperative medical complication, ICU till 7 days after surgery, length of stay (LOS) | none | GA vs. SA: 30-day mortality: GA = 691 (11.3%) vs. SA = 665 (10.8%), p = 0.44; ICU: GA = 371 (6%) vs.SA = 259 (4.2%), P < 0.001, 30-day postoperative medical complication: GA = 1.165 (19%), SA = 1.169 (19%) p = 0.92; LOS in days (± standard deviation): GA = 16.1 (20.2), SA = 16.0 (23.6), p = 0.72 | GA and SA were associated with similar rates of most postoperative events. |
Sevtap et al. 2013 [20] | Retrospective observational study | GA vs. SA vs. EA |
n = 185 GA = 67 (36.21%) SA = 67 (36.21%) EA = 51 (27.58%) | 7-day mortality, 30-day-mortality | Blood loss, blood transfusion, length of stay (LOS) | 7-day mortality: GA = 3 (4.4%), SA = 2 (2.9%), EA = 1 (1.9%), p = 0.738; 30-day mortality: GA = 4 (1.4%), SA = 6 (5.9%), EA = 4 (5.8%), p = 0.805; LOS: GA = 13.6 ± 8.9, SA = 12.5 ± 5.2, EA = 15.7 ± 9.4, p = 0.228 | There was no difference in the 7-day and 30-day mortality between the anaesthesia techniques. Further there were no differences in the other factors. |
Tung et al. 2016 [24] | Retrospective observational study | GA vs. RA (epidural/spinal) |
n = 17.189 GA = 6.063 (35.1%) NA = 11.153 (64.9%) | 30-day all-cause mortality, 30-day all cause readmission, 30-day specific cause readmission | 30-day mortality: GA = 104 (1.7%), NA = 189 (1.7%), p = 0.891, (OR 0.89, 95% CI [0.67 to 1.18], p = 0.409) 30-day readmission all-cause: GA = 771 (12.8%), NA = 1332 (12%), (OR 0.83, 95% CI 0.75 to0.93, p = 0.001), Surgical site infection readmission: (OR 0.69, 95% CI 0.49 to 0.97, p = 0.031) | There was no difference in the 30-day mortality between the two groups. NA is associated with a decreased 30-day all-cause readmission and surgical site infection readmission compared to GA | |
White et al. 2014 [21] | Retrospective observational study | GA vs. SA |
n = 65.535 GA = 35.373 (53.97%) SA = 23.665 (36.11%) | 30-day mortality | none | 30-day mortality: GA = 1.066 (7.0%) vs. SA = 1.345 (7.3%); p = 0.053 | No differences between GA and SA. |
White et al. 2016 [26] | Retrospective observational study | GA vs. SA (with or without peripheral nerve block) |
n = 11.085 GA = 985 GA with block = 4.364 GA + SA = 458 SA = 1.506 SA with block = 3.234 Unknown = 538 | 30-day mortality Length of stay (IQR [range]) Intraoperative blood pressure | None | 30-day mortality: GA vs. SA: 53 (5.4) vs. 87 (5.8) LOS: GA (n = 883): 13.2 (8.0-23.4 [1.3-165.8]) vs. SA (n = 1.319): 13.2 (8.0-22.8 [0.2-287.9]) | There was no significant difference in the 30-day mortality and the length of stay between the groups. |
Whiting et al. 2015 [22] | Retrospective observational study | GA vs. NA |
n = 7.764 GA = 5.840 (75.2%) NA = 1.924 (24.8%) (SA = 1.813 (23.4%); nerve block = 111 (1.4%)) | Minor complications, major complications, total complications within 30-day postoperative; 30-day mortality | none | SA vs GA: minor complications (OR: 1.43; CI 95%: 1.15 to 1.77; p = 0.001), major complications (OR: 1.01; CI 95%: 0.81 to 1.24; p = 0.950), total complications (OR: 1.24; CI 95%: 1.05 to 1.48; p = 0.014), 30-day mortality (OR: 1.20; CI 95%: 0.92 to 1.56; p = 0.169) | NA was associated with significantly greater odds of minor and total perioperative complications compared with GA. |
Risk of bias within and across studies
Author | Bias due to confounding | Bias in selection of participants | Bias in measurement of intervention | Bias due to departures from intended interventions | Bias to missing data | Bias in measurement of outcome | Bias in selection of the reported result | Overall bias |
---|---|---|---|---|---|---|---|---|
Basques et al. 2015 [8] | Low risk | High risk | High risk | Low risk | Low risk | Low risk | Low risk | Moderate risk. |
Explanation | The authors used calculated propensity scores to mitigate the selection bias. | Comparison group was retrospectively determined according to anaesthesia technique (SA vs. GA). | The ACS-NSQIP database does not capture the type or anaesthetic dosage used. | It is a retrospective study. There were no departures from intended interventions. | No important data missing. | The database was filled with data from medical records and interviews by trained reviewers. | The authors used bivariate and propensity-adjusted multivariate regression analyses. Binary outcomes were compared using logistic regression. | |
Brox et al. 2016 [23] | Low risk | High risk | High risk | Low risk. | Low risk | High risk | Low risk. | High risk. |
Explanation | The authors used Pearson’s chi-squared test and the Kruskal-Wallis test to mitigate selection bias. | Comparison group was retrospectively determined according to anaesthesia technique (SA vs. GA). | The database does not capture the type or dose of anaesthetic used. | It is a retrospective study. There were no departures from intended interventions | No important data missing. | A hip fracture registry was used to identify the patients. No information about the people collecting the data. | The authors used a multivariable conditional logistic regression model. | |
Chu et al. 2015 [25] | Low risk | High risk | High risk | Low risk. | Low risk | Unclear risk | Low risk | Moderate risk |
Explanation | The author used calculated propensity score to mitigate the selection bias. | Comparison group was retrospectively determined according to anaesthesia technique (GA vs. NA). | The database does not capture the type or dose of anaesthetic used. | It is a retrospective study. There were no departures from intended interventions | No important data missing. | A database was used without information of the people | The author used a propensity score, Student t test, Pearson chi-square test. | |
Fields et al. 2010 [9] | Low risk | High risk | High risk | Low risk | Low risk | Low risk | Low risk | Moderate risk |
Explanation | The authors used calculated propensity scores to mitigate the selection bias. | Comparison group was retrospectively determined according to anaesthesia technique (SA vs. GA). | The database does not capture the type or dose of anaesthetic used. | It is a retrospective study. There were no departures from intended interventions. | No important data missing. | A surgical clinical reviewer at each hospital collects the data. | The authors used a multivariate logistic regression. | |
Helwani et al. 2015 [10] | Low risk | High risk | High risk | Low risk | Low risk | Low risk | Low risk | Moderate risk |
Explanation | The authors used a propensity score to reduce the selection bias | Comparison group was retrospectively determined according to anaesthesia technique (GA vs. NA). | The database does not capture the type or dose of anaesthetic used. | It is a retrospective study. There were no departures from intended interventions. | No important data missing. | Dedicated data personnel collect, validate and submit the data after rigorous uniform training and examination. | Demographic and clinical characteristics were compared between the two groups by using Pearson chi-square test for all categorical variables. | |
Karademir et al. 2014 [11] | High risk | High risk | High risk | Low risk | High risk | High risk | Low risk | High risk |
Explanation | Retrospective study with high risk of confounders | Comparison group was retrospectively determined according to anaesthesia technique and the surgery technique (GA vs. NA). | The database does not capture the type or dose of anaesthetic used. | No departure from intervention. | No exact data about the mortality rate in the NA and the GA group. | The data were recruited from hospital data base and patient files. | The authors used a survival analysis by Kaplan-Meier method and a cox regression model. | |
Karaman et al. 2015 [12] | High risk | High risk | High risk | Low risk | Low risk | High risk | Low risk | High risk |
Explanation | Retrospective study with high risk of confounders. | Comparison group was retrospectively determined according to anaesthesia technique (GA vs. NA anaesthesia). | The dose and type of anaesthetic used is not described. | It is a retrospective study. There were no departures from intended interventions. | No missing data. | Patient screening was performed retrospectively from hospital electronic medical record system. | The authors used the Student t-test and the Yates Continuity Correction test to compare the results between the two groups. | |
Kim et al. 2013 [13] | High risk | High risk | High risk | Low risk | Low risk | High risk | Low risk | High risk |
Explanation | Retrospective study with high risk of confounders. | The three groups (GA vs. SA vs. EA) were retrospectively determined according to anaesthesia technique. | The study does not describe the dose and type of anaesthetic used. Especially the dose could differ between the individuals. | No departure from intervention. | No missing data. | No information about the way the results were collected. | The authors used a chi-square test, Fisher’s exact test and binary logistic regression analysis to review the results. | |
Le-Wendling et al. 2012 [14] | Low risk | High risk | High risk | Low risk | Low risk | Low risk | Low risk | Moderate risk |
Explanation | The authors used calculated propensity scores to mitigate the selection bias | The two groups (GA vs. RA) were retrospectively determined according to anaesthesia technique. | The study does not describe the dose and type of anaesthetic used. Especially the dose could differ between the individuals. | No departure from intervention. | No missing data. | The hospital service support analyst collected the data. | The authors used a multiple logistic regression model and a linear regression model to compare the result. | |
Neuman et al. 2012 [27] | Low risk | High risk | High risk | Low risk | Low risk | Low risk | Low risk | Low risk |
Explanation | The author used calculated propensity scores to mitigate selection bias. | The two groups (GA vs. NA) were retrospectively determined according to anaesthesia technique. | The study does not describe the dose and type of anaesthetic used. Especially the dose could differ between the patients. | No departure from intervention. | No missing data. | The results were collected in the New York State Inpatient Database which was overseen by the U.S. Agency for Healthcare. | The author used the Wilcoxon rank sum test and the chi-square test to compare the results. | |
Neumann et al. 2014 [15] | Low risk | High risk | High risk | Low risk | Low risk | High risk | Low risk | High risk. |
Explanation | The authors used near-far matching, standardized differences, across-hospitalmatch and a within-hospital match to reduce the selection bias. | The two groups (GA vs. EA) were retrospectively determined according to anaesthesia technique. | The study does not describe the dose and type of anaesthetic used. | No departure from intervention. | No missing data. | No information about the way the results were collected | The authors used an instrumental variable method, the McNemar test and the x2 statistic to compare the results. | |
Patorno et al. 2014 [16] | High risk | High risk | High risk | Low risk | Low risk | Low risk | Low risk | High risk. |
Explanation | Retrospective study with high risk of confounders. | The three groups (GA vs. NA, GA + NA) were retrospectively determined according to the anaesthesia technique. | The data does not capture the dosage and type of anaesthetic used. The does could differ between the patients. | No departure from intervention. | No missing data. | The authors used the Premier research database. The data were collected from member hospitals through Premier’s informatics products. | The authors used a multi-variable logistic regression to compare the results. | |
Rashid et al. 2013 [17] | High risk | High risk | High risk | Low risk | Low risk | High risk | High risk | High risk |
Explanation | Retrospective study with high risk of confounders. | The two groups (GA vs. NA) were retrospectively determined according to anaesthesia technique. | The study does not describe the dose and type of anaesthetic used. The does could differ between the patients. | No departure from intervention. | No missing data. | Unclear how the data were collected and how the clinical measurement was done. | The authors use SPSS version 19 for statistical analyses. However no information is given on the type of analysis | |
Seitz et al. 2014 [19] | Low risk | High risk | High risk | Low risk | Low risk | Low risk | Low risk | Moderate risk. |
Explanation | The authors used calculated propensity scores to mitigate the selection bias. | The two groups (GA vs. NA) were retrospectively determined according to anaesthesia technique. | The study does not describe the dose and type of anaesthetic used. The does could differ between the patients. | No departure from intervention. | No missing data. | The used data sets were linked using unique, encoded identifiers and analysed at the Institute for Clinical Evaluative Sciences (ICES). | The authors used the Wilcoxon rank-sum test and chi-square test to compare the results. | |
Shih et al. 2010 [18] | High risk | High risk | Low risk | Low risk | Low risk | High risk | Low risk | High risk. |
Explanation | Retrospective study with high risk of confounders. | The two groups (GA vs. NA) were retrospectively determined according to anaesthesia technique. | The measurement of intervention is well-defined. | No departure from intervention. | No missing data. | Unclear how the data were collected and how the clinical measurement was done. | The authors used Student t-test, X2 or Fisher exact test and logistic regression to compare the results. | |
Sevtap et al. 2013 [20] | High risk | High risk | Low risk | Low risk | Low risk | High risk | Low risk | High risk. |
Explanation | Retrospective study with high risk of confounders. | The three groups (GA vs. SA vs. EA) were retrospectively determined according to the anaesthesia technique. | The measurement of intervention is well-defined. | No departure from intervention. | No missing data. | This is a retrospective study. And all the data were obtained from the medical data. | The authors used the one-way analysis of variance test for normally distributed data and the Kruskal Wallis test for abnormally distributed data. The categorical variables were compared using the chi-square tests. | |
Tung et al. 2016 [24] | Low risk. | High risk. | High risk. | Low risk. | Low risk. | High risk. | Low risk. | High risk. |
Explanation | The authors used calculated propensity scores to mitigate the selection bias. | The two groups (GA vs. NA) were retrospectively determined according to anaesthesia technique. | The study does not describe the dose and type of anaesthetic used. The dose could be different between the patients. | No departure from intervention. | No missing data. | Data were collected in the National Health Insurance research database. No information about the persons collecting the information. | The authors used a generalized estimation equation logistic regression model and propensity score. | |
White et al. 2014 [21] | High risk | High risk | High risk | Low risk | Low risk | Low risk | Low risk | High risk. |
Explanation | Retrospective study with high risk of confounders. | The two groups (GA vs. SA) were retrospectively determined according to anaesthesia technique. | The study does not describe the dose and type of anaesthetic used. | No departure from intervention. | No missing data. | Data were collected by specially trained personnel employed by each eligible hospital. | The authors used a two-tailed chi-squared test without Yate’s correction and multivariable regression analysis. | |
White et al. 2016 [26] | High risk. | High risk | High risk | Low risk | High risk | Low risk | Low risk | High risk |
Explanation | Retrospective study with high risk of confounders. | The two groups (GA vs. SA) were retrospectively determined according to anaesthesia technique. | The study described the different volumes used for intrathecal injections. However the dose and type for the general anaesthesia or the peripheral nerve block were not described. | No departure from intervention. | 16.904 patient records. However only 11.085 could be analysed. | Data were collected by specially trained personnel employed by each eligible hospital. | The authors used Fisher’s exact test, chi-squared, Wilcoxon and Haenzel tests. | |
Whiting et al. 2015 [22] | High risk | High risk | High risk | Low risk | Low risk | Low risk | Low risk | High risk. |
Explanation | Retrospective study with high risk of confounders | The two groups (GA vs. NA) were retrospectively determined according to anaesthesia technique. | The study does not describe the dose and type of anaesthetic used. The dose could be different between the patients. | No departure from intervention. | No missing data. | Data were collected at each hospital directly from patients medical records through risk-assessment nurses trained as Surgical Clinical Reviewers (SCR) | The authors used chi-square, Fischer’s exact test and multivariate models. |
Author | Random sequence generation (selection bias) | Allocation concealment (selection bias) | Blinding of participants and personnel (performance bias) | Blinding of outcome assessment (detection bias) | Incomplete outcome data addressed (attrition bias) | Selective reporting (reporting bias) | Other bias |
---|---|---|---|---|---|---|---|
Biboulet et al. 2012 [32] | Unclear risk | Unclear risk | Unclear risk | Unclear risk | Low risk | Low risk | Unclear risk |
Explanation | No information about the sequence generation process. | Method of concealment is not described. | Insufficient information about blinding of participants or personnel. | Insufficient information about blinding of outcome assessment. | No incomplete outcome data. | The paper included all expected outcome. | The authors described several limitations which could influence the outcome. |
Heidari et al. 2011 [33] | Low risk | Unclear Risk | Low risk | Unclear risk | Low risk | Low risk | Unclear risk |
Explanation | A random-number table was used. | Method of concealment is not described. | It was not possible to blind the patient or the anaesthetist. | Insufficient information about blinding of outcome assessment. | No incomplete outcome data. | The paper included all expected outcomes. | The author described several limitations, which could influence the outcomes. |
Parker et al. 2015 [31] | Unclear risk | Unclear risk | High risk | Low risk | Low risk | Low risk | Unknown risk |
Explanation | Randomisation was undertaken by the opening of sealed opaque numbered envelopes. The envelopes were prepared at the start of the study by a person independent to the study. | Randomisation was undertaken by the opening of sealed opaque numbered envelopes. The envelopes were prepared at the start of the study by a person independent to the study. | The exact technique and doses of the anaesthetic used was the choice of the anaesthetist. On the verge of surgery the patient knows if he gets a general or spinal anaesthesia. | There was no blinding of investigator, participants or outcome assessors without having influence on outcomes like 30-day mortality. | Attrition <1%. | No important outcomes missing. | Small numbers of patients being included. |
Results of individual studies
Mortality
Author/Reference | Study type | Anaesthesia | Sample size | Outcome parameter | Results | Conclusion |
---|---|---|---|---|---|---|
Basques et al. 2015 [8] | Retrospective observational study | GA vs. SA |
n = 9.842 GA = 7.253 (73.7%) SA = 2.589 (26.3%) | 30-day mortality | GA vs. SA: 6.2% vs. 6.4%; (OR 0.98, 95% CI 0.82 to 1.20, p = 0.908) | There was no difference related to the mortality. |
Biboulet et al. 2012 [32] | Randomised controlled study | SA vs. GA (propofol, sevoflurane) |
n = 45 GA = 30 SA = 15 | 30-day mortality | SA vs.GA: 1 (6.7%) vs. 1(7.1%), p = 0.76 | There was no difference related to the mortality |
Brox et al. 2016 [23] | Retrospective observational study | GA vs. SA |
n = 7.585 GA = 4.257 (56%) SA = 3.059 (40%) Mixed = 269 (4%) | 30-day mortality | 30-day mortality: GA = 177 (4%) vs. SA = 113 (4%) | There was no difference related to the mortality. |
Fields et al. 2010 [9] | Retrospective observational study | GA vs. SA |
n = 6.133 GA = 4.318 (72.6%) SA = 1.815 (27.4%) | 30-day mortality | SA vs. GA: 30-day mortality: 6.67% vs. 5.84%, p = 0.21 | There was no difference related to the mortality. |
Heidari et al. 2011 [33] | Randomised controlled study | GA vs. NA (Epidural/spinal) |
n = 387 GA = 197 NA = 190 | 30-day mortality | GA vs. SA: 0 vs. 2, p = 0.299 | There was no differencerelated to the mortality. |
Helwani et al. 2015 [10] | Retrospective observational study | GA vs. NA(SA/EA) |
n = 12.929 GA = 7.826 (60.5%) RA = 5.103 (39.5%) [SA = 4.377 (85.8%); EA = 126 (2.5%)] | 30-day mortality | NA vs. GA: OR 0.78, 95% CI 0.43 to 1.42; p > 0,05 | There was no difference in the mortality. |
Kim et al. 2013 [13] | Retrospective observational study | GA vs. SA vs. EA |
n = 506 GA = 246 (48.62%) SA = 249 (49.21%) EA = 11 (2.17%) | 30-day mortality | GA = 7 (2.8%); SA = 4 (1.6%); EA = 0 (0.0%); p = 0.57 | There was no difference in the mortality. |
Neuman et al. 2014 [15] | Retrospective observational study | GA vs. NA (spinal/epidural) |
n = 56.729 GA = 40.825 (72%) RA = 15.904 (28%) | 30-day mortality | RA = 5.3%, GA = 5.4% (difference 0.1%; 95% CI 0.5 to 0.3; p = 0.55) | 30-day mortality did not differ significantly between GA and NA. |
Parker et al. 2015 [31] | Randomised controlled study | GA vs. SA |
n = 322 GA = 164 (50.93%) SA = 158 (49.07%) | 30-day mortality | 30-day mortality: GA vs SA: 8 (4.9%) vs. 5 (3.2%); p = 0.57 | There was no difference in the mortality. |
Seitz et al. 2014 [19] | Retrospective observational study | GA (inhalational, intravenous, GA combined with epidural or local anaesthesia) vs. SA |
n = 20.973 GA = 8.818 (42.1%) SA = 12.155 (57.9%) | 30-day mortality | GA vs. SA: 30-day mortality: GA = 691 (11.3%) vs. SA = 665 (10.8%), p = 0.44 | There was no difference in the mortality. |
Sevtap et al. 2012 [20] | Retrospective observational study | GA vs. SA vs. EA |
n = 185 GA = 67 (36.21%) SA = 67 (36.21%) EA = 51 (27.58%) | 30-day-mortality | 30-day mortality: GA = 4 (1.4%), SA = 6 (5.9%), EA = 4 (5.8%), p = 0.805 | There was no difference in the mortality. |
Tung et al. 2016 [24] | Retrospective observational study | GA vs. NA |
n = 17.189 GA = 6.063 (35.1%) RA = 11.153 (64.9%) | 30-day mortality | 30-day mortality: GA = 104 (1.7%), NA = 189 (1.7%), p = 0.891, (OR 0.89, 95% CI 0.67 to 1.18, p = 0.409) | There was no difference in the mortality. |
White et al. 2014 [21] | Retrospective observational study | GA vs. SA |
n = 65.535 GA = 35.373 (53.97%) SA = 23.665 (36.11%) | 30-day mortality | 30-day mortality: GA = 1.066 (7.0%) vs. SA = 1.345 (7.3%); p = 0.053 | No notable differences between GA and SA. |
White et al. 2016 [26] | Retrospective observational study | GA vs. SA (with or without peripheral nerve block) |
n = 11.085 GA = 985 GA with block = 4.364 GA + SA = 458 SA = 1.506 SA with block = 3.234 Unknown = 538 | 30-day mortality | 30-day mortality: GA vs. SA: 291 (5.4%) vs. 224 (4.7%) | No notable differences between GA and SA. |
Author/Reference | Study type | Anaesthesia | Sample size | Outcome parameter | Results | Conclusion |
---|---|---|---|---|---|---|
Chu et al. 2015 [25] | Retrospective observational study | GA vs. NA (spinal/epidural) |
n = 104.088 GA = 52.044 NA = 52.044 | In-hospital mortality | GA vs. NA: 1.363 (2.62%) vs. 1.107 (2.13%), p < 0.001 | The incidence of on-hospital mortality was significantly lower in the NA group. |
Heidari et al. 2011 [33] | Randomised controlled study | GA vs. NA (epidural/spinal) |
n = 270 GA = 197 NA = 190 | In-hospital mortality | GA vs. NA: 0 vs. 5, p = 0.107 | The incidence of in-hospital mortality was similar in both groups. |
Le-Wendling et al. 2012 [14] | Retrospective observational study | GA vs. RA (single injection spinal, continuous spinal, continuous epidural) with or without continuous nerve block |
n = 308 GA = 235 (76.30%); RA = 73 (23.70%) | In-hospital mortality | RA vs. GA: 2 (2.74) vs. 9 (3.83) | There was no difference between the in-hospital mortality. |
Neuman et al. 2012 [27] | Retrospective observational study | GA vs. NA |
n = 18.158 GA = 12.904 NA = 5.254 | In-hospital mortality | GA vs NA 325 (2.5%) vs. 110 (2.1%), p = 0.090 | There was no difference for the in-hospital mortality between the two groups. |
Patorno et al. 2014 [16] | Retrospective observational study | GA vs NA (spinal/epidural) vs. GA + NA |
n = 73.284 GA = 61.554 (84.0%) NA = 6.939 (9.47%); GA + RA = 4.791 (6.53%) | In-hospital mortality | In-hospital mortality: GA vs. NA: 144 vs. 1362 (risk ratio 0.93, 95% CI 0.78 to 1.11) | Mortality risk did not differ significantly between GA and NA. |
Length of hospital stay
Author/Reference | Study type | Anaesthesia | Sample size | Outcome parameter | Results | Conclusion |
---|---|---|---|---|---|---|
Basques et al. 2015 [8] | Retrospective observational study | GA vs. SA |
n = 9.842 GA = 7.253 (73.7%) SA = 2.589 (26.3%) | Length of hospital stay (LOS) | LOS: GA vs SA: (HR: 1.28, 95% CI 1.22 to 1.34, p < 0.001) | GA was associated with a shorter LOS. |
Chu et al. 2015 [25] | Retrospective observational study | GA vs. NA (spinal/epidural) |
n = 104.088 GA = 52.044 NA = 52.044 | Length of hospital stay | LOS: GA vs. NA: 10.77 (8.23) vs. 10.44 (6.67), p < 0.001 | The length of hospital stay was significantly shorter in the neuraxial anaesthesia group. |
Heidari et al. [33] | Randomised controlled trial | GA vs. NA (spinal/epidural) |
n = 387 GA = 197 NA = 190 | Length of hospital stay | LOS: GA vs. NA: 8.4 (3.5) vs. 7.7 (3.4) | The length of hospital stay was significantly shorter in the NA group. |
Helwani et al. 2015 [10] | Retrospective observational study | GA vs NA (SA/EA) |
n = 12.929 GA = 7.826 (60.5%) NA = 51.03 (39.5%) [SA = 4.377 (85.8%); EA = 126 (2.5%)] | Length of hospital stay (LOS) | LOS: OR = 0.73; 95% CI = 0.68 to 0.89, p < 0.001 | NA anaesthesia was associated with a reduction in LOS. |
Le-Wendling et al. 2012 [14] | Retrospective observational study | GA vs. RA (single injection spinal, continuous spinal, continuous epidural) with or without continuous nerve block |
n = 308 GA = 235 (76.30%); RA = 73 (23.70%) | Length of hospital stay (LOS) | LOS: RA vs. GA: 6.4 vs. 6.6 days, p = 0.64 | There was no difference in the length of hospital stay. |
Neuman et al. 2014 [15] | Retrospective observational study | GA vs. NA (spinal/epidural) |
n = 56.729 GA = 40.825 (72%) NA = 15.904 (28%) | Length of hospital stay (LOS) | LOS: NA = 6 days (95% CI: 6 to 6.1) vs. GA = 6.3 days (95% CI: 6.2 to 6.3), p < 0.001 | NA was associated with modestly shorter LOS. |
Parker et al. 2016 [31] | Randomised controlled study | GA vs. SA |
n = 322 GA = 164 (50.93%) SA = 158 (49.07%) | Length of hospital stay (LOS) | LOS in days (standard deviation): GA = 15.9 (13.7); SA = 16.2 (14.6); p = 0.75 | There was no difference in the length of hospital stay. |
Rashid et al. 2013 [17] | Retrospective observational study | GA vs. NA(epidural/spinal) |
n = 194 GA = 107 (55.15%) NA = 87 (44.85%) | Length of hospital stay (LOS) | LOS: GA = 9.35 ± 9.0, NA = 8.63 ± 3.6, p = 0.484 | There were no statistic differences between LOS. |
Shih et al. 2010 [18] | Retrospective observational study | GA vs. SA |
n = 335 GA = 167 (49.85%) SA = 168 (50.15%) | Length of hospital stay (LOS) | LOS:GA vs. SA 9 (4-45) days vs. 8 (2-92) days, p = 0.04 | The LOS was significantly shorter in the spinal anaesthesia group. |
Seitz et al. 2014 [19] | Retrospective observational study | GA (inhalational, intravenous, GA combined with epidural or local anaesthesia) vs. SA |
n = 20.973 GA = 8.818 (42.1%) SA = 12.155 (57.9%) | Length of hospital stay (LOS) | LOS in days (± standard deviation): GA = 16.1 (20.2), SA = 16.0 (23.6), p = 0.72 | There was no difference in the length of hospital stay |
Sevtap et al. 2013 [20] | Retrospective observational study | GA vs. SA vs. EA |
n = 185 GA = 67 (36.21%) SA = 67 (36.21%) EA = 51 (27.58%) | Length of hospital stay (LOS) | LOS: GA = 13.6 ± 8.9, SA = 12.5 ± 5.2, EA = 15.7 ± 9.4, p = 0.228 | There was no difference in the length of hospital stay |
White et al. 2016 [26] | Retrospective observational study | GA vs. SA (with or without peripheral nerve block) |
n = 10,564 GA = 5508 SA = 5056 | Length of hospital stay (SD) | LOS: GA vs. SA: 19.12 (20.03) vs. 18.70 vs. 18.37 | There was no difference in the length of hospital stay |
Secondary outcomes
Cardiac complications/myocardial infarction
Author/Reference | Study type | Anaesthesia | Sample size | Outcome parameter | Results | Conclusion |
---|---|---|---|---|---|---|
Basques et al. 2015 [8] | Retrospective observational study | GA vs. SA |
n = 9.842 GA = 7.253 (73.7%) SA = 2.589 (26.3%) | Myocardial infarction | SA vs. GA: 1.9% vs. 1.9%; OR 1.00, 95% CI 0.71 to 1.39, p = 0.510 | The incidence of myocardial infarction was similar in the two groups. |
Biboulet et al. 2012 [32] | Randomised controlled study | GA vs. SA (propofol, sevoflurane) |
n = 45 GA = 30 SA = 15 | Myocardial infarction | SA vs. GA: 0 vs. 1, p = 1.0 | The incidence of myocardial infarction was similar between the two groups. |
Chu et al. 2015 [25] | Retrospective observational study | GA vs. NA (spinal/epidural) |
n = 104.088 GA = 52.044 NA = 52.044 | Myocardial infarction | NA vs. GA: 169 (0.32%) vs. 188 (0.36%), p = 0.31 | The incidence of myocardial infarction was similar between the two groups. |
Fields et al. 2010 [9] | Retrospective observational study | GA vs. SA |
n = 6.133 GA = 4.318 (72.6%) SA = 1.815 (27.4%) | Myocardial infarction | SA vs. NA: 1.71% vs. 1.75%, p = 0.92 | The incidence of myocardial infarction was similar between the two groups. |
Heidari et al. 2011 [33] | Randomised controlled study | GA vs. NA (EA/SA) |
n = 270 GA = 197 NA = 190 | Myocardial infarction | NA vs. GA: 1 (0.6%) vs. 1 (0.5%), | The incidence of myocardial infarction was similar between the two groups. |
Neuman et al. 2012 [27] | Retrospective observational study | GA vs. NA |
n = 18.158 GA = 12.904 NA = 5.254 | Myocardial infarction | NA vs. GA: 97 (1.9%) vs. 266 (2.1%), p = 0.348 | The incidence of myocardial infarction was similar between the two groups. |
Parker et al. 2015 [31] | Randomised controlled study | GA vs. SA |
n = 322 GA = 164 (50.93%) SA = 158 (49.07%) | Myocardial infarction | SA vs. GA: 1 (0.6%) vs. 1 (0.6%), p = 1.0 | The incidence of myocardial infarction was similar between the two groups. |
Seitz et al. 2014 [19] | Retrospective observational study | GA (inhalational, intravenous, GA combined with epidural or local anaesthesia) vs. SA |
n = 20.973 GA = 8.818 (42.1%) SA = 12.155 (57.9%) | Myocardial infarction | SA vs. GA: 454 (7.4%) vs. 501 (8.2%), p = 0.07 | The incidence of myocardial infarction was similar between the two groups. |
Tung et al. 2016 [24] | Retrospective observational study | GA vs. RA (epidural/spinal) |
n = 17.189 GA = 6.063 (35.1%) NA = 11.153 (64.9%) | Myocardial infarction | NA vs. GA: 10 (0.1%) vs. 10 (0.1%), p = 0.162 | The incidence of myocardial infarction was similar between the two groups. |
Whiting et al. 2015 [22] | Retrospective observational study | GA vs. SA |
n = 7.764 GA = 5.840 SA = 1.813 | Myocardial infarction | SA vs. GA: Odds ratio 0.84; 95% CI 0.50-1.43, p = 0.532 | The incidence of myocardial infarction was similar between the two groups. |
Pulmonary complications
Author/Reference | Study type | Anaesthesia | Sample size | Outcome parameter | Results | Conclusion |
---|---|---|---|---|---|---|
Basques et al. 2015 [8] | Retrospective observational study | GA vs. SA |
n = 9.842 GA = 7.253 (73.7%) SA = 2.589 (26.3%) | Pneumonia | SA vs. GA: 4.2% vs. 3.6%, OR 0.84, 95% CI 0.67 to 0.1.07, p = 0.154 | The incidence of pneumonia was similar between the two groups. |
Chu et al. 2015 [25] | Retrospective observational study | GA vs. NA (spinal/epidural) |
n = 104.088 A = 52.044 NA = 52.044 | Acute respiratory failure | NA vs. GA: 328 (0.63%) vs. 868 (1.67), p < 0001 | The incidence of respiratory failure was significantly lower in the neuraxial group. |
Fields et al. 2010 [9] | Retrospective observational study | GA vs. SA |
n = 6.133 GA = 4.318 (72.6%) SA = 1.815 (27.4%) | Pneumonia Pulmonary embolism | Pneumonia: SA vs. GA: 3.58% vs. 3.55%, p = 0.96; Pulmonary embolism: 0.45% vs. 0.89%, p = 0.10 | The incidence of pneumonia and pulmonary embolism was similar between the two groups. |
Heidari et al. 2011 [33] | Randomised controlled study | GA vs. NA (EA/SA) |
n = 270 GA = 197 NA = 190 | Pneumonia | NA vs. GA: 1 (0.6%) vs. 0 | The incidence of pneumonia was similar between the two groups. |
Neuman et al. 2012 [27] | Retrospective observational study | GA vs. NA |
n = 18.158 GA = 12.904 NA = 5.254 | Pneumonia, Respiratory failure | Pneumonia: NA vs. GA: 153 (2.9%) vs. 359 (2.8%), p = 0.631;Respiratory failure: 180 (3.4%) vs. 641 (5.0%), p < 0.0001 | The incidence of pneumonia was similar in both groups. The incidence of respiratory failure was significant lower in neuraxial anaesthesia group. |
Parker et al. 2015 [31] | Randomised controlled study | GA vs. SA |
n = 322 GA = 164 (50.93%) SA = 158 (49.07%) | Pneumonia Pulmonary embolism | Pneumonia: SA vs. GA: 2 (1.3%) vs. 3 (1.8%), p = 1.0; Pulmonary embolism: 0 vs. 2 (1.2%), p = 0.50 | The incidence of pneumonia and pulmonary embolism was similar in both groups. |
Seitz et al. 2014 [19] | Retrospective observational study | GA (inhalational, intravenous, GA combined with epidural or local anaesthesia) vs. SA |
n = 20.973 GA = 8.818 (42.1%) SA = 12.155 (57.9%) | Pneumonia Pulmonary embolism | Pneumonia: SA vs. GA: 413 (6.7%) vs. 399 (6.5%), p = 0.61; Pulmonary embolism: 49 (0.9%) vs. 67 (1.1%) p = 0.09 | The incidence of pneumonia and pulmonary embolism was similar in both groups. |
Shih et al. 2010 [18] | Retrospective observational study | GA vs. SA |
n = 335 GA = 167 (49.85%) SA = 168 (50.15%) | Pneumonia, Respiratory failure | Pneumonia: SA vs. GA: 3 vs. 9; Respiratory failure: 0 vs. 1 | The incidence of pneumonia was significantly higher in the general anaesthesia group. The incidence of respiratory failure was similar between the two groups. |
Tung et al. 2016 [24] | Retrospective observational study | GA vs. RA (epidural/spinal) |
n = 17.189 GA = 6.063 (35.1%) NA = 11.153 (64.9%) | Pneumonia | NA vs. GA: 59 (1.0%) vs. 159 (1.4%), p = 0.012 | The incidence of pneumonia was significantly higher in the general anaesthesia group. |
Whiting et al. 2015 [22] | Retrospective observational study | GA vs. SA |
n = 7.764 GA = 5.840 SA = 1.813 | Pneumonia Pulmonary embolism | Pneumonia: SA vs. GA: Odds ratio 1.19, 95% CI 0.83 to 1.71, p = 0.337; Pulmonary embolism: OR 0.48, 95% CI 0.18 to 1.23, p = 0.129 | The incidence of pneumonia and pulmonary embolism was similar between the two groups. |