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Anaesthesia for Hip Fracture Surgery in Adults Cochrane 2004

Anaesthesia for Hip Fracture Surgery in Adults Cochrane 2004

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  • C O V E R S H E E T
  • Issue protocol first published 1997/4
  • Review first published 1999/4
  • Date of most recent amendment 06 August 2003
  • Date of most recent
  • Date new studies sought but
  • Date new studies found but not
  • Date new studies found and
  • Date authors’ conclusions
  • Cochrane Library number CD000521
  • Comparison 04. 01 Mortality - 1 month
  • Comparison 04. 02 Mortality - 1 month (random effects model)
  • Comparison 04. 03 Mortality - 3 months
  • Comparison 04. 04 Mortality - 6 months
  • Comparison 04. 05 Mortality - 12 months
  • Comparison 04. 06 Mortality - early and up to 1 month
  • Comparison 04. 07 Length of operation (mins)
  • Comparison 04. 08 Operative hypotension
  • Comparison 04. 09 Operative hypotension (random effects model)
  • Comparison 04. 10 Operative blood loss (mls)
  • Comparison 04. 11 Patients receiving blood transfusion
  • Comparison 04. 12 Transfusion requirements (mls)
  • Comparison 04. 13 Post-operative hypoxia
  • Comparison 04. 14 Length of hospital stay
  • Comparison 04. 15 Pneumonia
  • Comparison 04. 16 Myocardial infarction
  • Comparison 04. 17 Cerebrovascular accident
  • Comparison 04. 18 Congestive cardiac failure
  • Comparison 04. 19 Renal failure
  • Comparison 04. 20 Acute confusional state
  • Comparison 04. 21 Urine retention
  • Comparison 04. 22 Vomiting
  • Comparison 04. 23 Deep vein thrombosis
  • Comparison 04. 24 Pulmonary embolism
  • Comparison 04. 25 Pulmonary embolism (random effects model)
  • Comparison 04. 26 Pulmonary embolism (fatal and non fatal)
  • Comparison 04. 02 Length of operation
  • Comparison 04. 03 Pneumonia
  • Comparison 04. 04 Confusional state
  • Comparison 04. 05 Deep vein thrombosis
  • Comparison 04. 01 Incomplete or unsatisfactory analgesia
  • Comparison 04. 02 Operative hypotension
  • Comparison 04. 03 Mean fall in arterial blood pressure (mmHg)
  • Comparison 04. 04 Mean dose of ephedrine used (mg)
  • Comparison 04. 05 Adverse effects
  • Comparison 04. 06 Post-operative confusion
  • Comparison 04. 01 Mortality - during hospital stay
  • Comparison 04. 02 Myocardial infarction
  • Comparison 04. 03 Congestive cardiac failure
  • Comparison 04. 04 Pulmonary embolism
  • Comparison 04. 05 Length of hospital stay (discharge home)

Anaesthesia for hip fracture surgery in adults (Review

)
Parker MJ, Handoll HHG, Griffiths R, Urwin SC

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2004, Issue 3 http://www.thecochranelibrary.com

Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

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TABLE OF CONTENTS ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . SYNOPSIS . . . . . . . . . . . . . . . . . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . SEARCH STRATEGY FOR IDENTIFICATION OF STUDIES . . . . . . . METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . REVIEWERS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . Characteristics of included studies . . . . . . . . . . . . . . . . Characteristics of excluded studies . . . . . . . . . . . . . . . . GRAPHS . . . . . . . . . . . . . . . . . . . . . . . . . . Comparison 01. Regional (spinal or epidural) versus general anaesthesia . . . Comparison 02. Spinal and ’light’ general anaesthetic versus general anaesthetic Comparison 03. Regional (spinal or epidural) versus lumbar plexus nerve blocks Comparison 04. Intravenous ketamine versus general anaesthesia . . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . Comparison 04. 01 Mortality - 1 month . . . . . . . . . . . . . . Comparison 04. 02 Mortality - 1 month (random effects model) . . . . . Comparison 04. 03 Mortality - 3 months . . . . . . . . . . . . . Comparison 04. 04 Mortality - 6 months . . . . . . . . . . . . . Comparison 04. 05 Mortality - 12 months . . . . . . . . . . . . . Comparison 04. 06 Mortality - early and up to 1 month . . . . . . . . Comparison 04. 07 Length of operation (mins) . . . . . . . . . . . Comparison 04. 08 Operative hypotension . . . . . . . . . . . . . Comparison 04. 09 Operative hypotension (random effects model) . . . . Comparison 04. 10 Operative blood loss (mls) . . . . . . . . . . . . Comparison 04. 11 Patients receiving blood transfusion . . . . . . . . Comparison 04. 12 Transfusion requirements (mls) . . . . . . . . . . Comparison 04. 13 Post-operative hypoxia . . . . . . . . . . . . . Comparison 04. 14 Length of hospital stay . . . . . . . . . . . . . Comparison 04. 15 Pneumonia . . . . . . . . . . . . . . . . . Comparison 04. 16 Myocardial infarction . . . . . . . . . . . . . Comparison 04. 17 Cerebrovascular accident . . . . . . . . . . . . Comparison 04. 18 Congestive cardiac failure . . . . . . . . . . . . Comparison 04. 19 Renal failure . . . . . . . . . . . . . . . . Comparison 04. 20 Acute confusional state . . . . . . . . . . . . . Comparison 04. 21 Urine retention . . . . . . . . . . . . . . . Comparison 04. 22 Vomiting . . . . . . . . . . . . . . . . . Comparison 04. 23 Deep vein thrombosis . . . . . . . . . . . . .
Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

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Comparison 04. 24 Pulmonary embolism . . . . . . . . Comparison 04. 25 Pulmonary embolism (random effects model) Comparison 04. 26 Pulmonary embolism (fatal and non fatal) . Comparison 04. 01 Mortality - 1 month . . . . . . . . . Comparison 04. 02 Length of operation . . . . . . . . . Comparison 04. 03 Pneumonia . . . . . . . . . . . . Comparison 04. 04 Confusional state . . . . . . . . . . Comparison 04. 05 Deep vein thrombosis . . . . . . . . Comparison 04. 01 Incomplete or unsatisfactory analgesia . . Comparison 04. 02 Operative hypotension . . . . . . . . Comparison 04. 03 Mean fall in arterial blood pressure (mmHg) Comparison 04. 04 Mean dose of ephedrine used (mg) . . . . Comparison 04. 05 Adverse effects . . . . . . . . . . . Comparison 04. 06 Post-operative confusion . . . . . . . Comparison 04. 01 Mortality - during hospital stay . . . . . Comparison 04. 02 Myocardial infarction . . . . . . . . Comparison 04. 03 Congestive cardiac failure . . . . . . . Comparison 04. 04 Pulmonary embolism . . . . . . . . Comparison 04. 05 Length of hospital stay (discharge home) . .

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Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

ii

Anaesthesia for hip fracture surgery in adults (Review)
Parker MJ, Handoll HHG, Griffiths R, Urwin SC

This record should be cited as: Parker MJ, Handoll HHG, Griffiths R, Urwin SC. Anaesthesia for hip fracture surgery in adults. The Cochrane Database of Systematic Reviews , Issue . Art. No.: CD000521. DOI: 10.1002/14651858.CD000521. This version first published online: 23 October 2001 in Issue , . Date of most recent substantive amendment: 04 July 2001

ABSTRACT 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. Search strategy We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2000), MEDLINE (1996 to December Week 4 2000) and reference lists of relevant articles. Selection criteria Randomised and quasi-randomised trials comparing different methods of anaesthesia for hip fracture surgery in skeletally mature persons. The primary focus of this review was the comparison of regional (spinal or epidural) anaesthesia versus general anaesthesia; this has been expanded to include other comparisons. The use of nerve blocks pre-operatively or in conjunction with general anaesthesia is evaluated in another review. The primary outcome was mortality. Data collection and analysis Two reviewers independently assessed trial quality, using a nine item scale, and extracted data. Results were pooled wherever appropriate and possible. Main results Seventeen trials, involving 2305 patients, comparing regional anaesthesia with general anaesthesia were included. All trials had methodological flaws. Pooled results from eight trials showed regional anaesthesia to be associated with a decreased mortality at one month (53/781(6.8%) versus 78/826(9.4%)); this was of borderline statistical significance (relative risk (RR) 0.72, 95% confidence interval (CI) 0.51 to 1.00). The results from six trials 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%), RR 0.92, 95% CI 0.71 to 1.21). The reduced numbers of patients 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%), RR 1.07, 95% CI 0.82 to 1.41). Regional anaesthesia was associated with a tendency to a longer operation (weighted mean difference 4.8 minutes, 95% CI 1.1 to 8.6 minutes), and a reduced risk of deep venous thrombosis (39/129 (30%) versus 61/130 (47%); RR 0.64, 95% CI 0.48 to 0.86), 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 four included trials, involving a total of 179 patients, which compared other methods of anaesthesia (a ’light’ general with spinal anaesthesia; intravenous ketamine; nerve blocks). Reviewers’ 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.
Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd 1

SYNOPSIS Regional anaesthesia may reduce the number of early deaths after hip fracture surgery but more evidence is needed to establish if it is better than general anaesthesia The majority of people with hip fracture are treated surgically. Anaesthesia is used to prevent pain during the operation. There are a number of different types of anaesthesia and the most common are ’general’ and ’spinal’. General anaesthesia, which usually involves a loss of consciousness, typically includes inhalation of gases. Spinal (regional) anaesthesia involves an injection into the space around the spinal cord, to prevent pain in the involved limb. Although there were fewer early deaths (within one month) in people given spinal anaesthesia, there was not enough clear evidence to tell if regional anaesthesia was superior to general anaesthesia. The effectiveness of other methods of anaesthesia could not be determined.

BACKGROUND The scope of this review, originally published in Issue 4, 1999, has been expanded in this update, published in Issue 4, 2001, to cover other methods of anaesthesia. However, the main focus remains the comparison of regional versus general anaesthesia. The term proximal femoral fracture, or ’hip fracture’, refers to a fracture of the femur in the area of bone immediately distal to the articular cartilage of the hip, to a level of about five centimetres below the lower border of the lesser trochanter. The majority of these fractures occur in an elderly population with an average age of around 80 years. Females predominate over males by about four to one (Parker 1993) and the injury is usually the result of a simple fall. Whilst the hip fracture is usually the only injury, the patients frequently have many other medical problems associated with aging. An estimated 1.7 million hip fractures occurred worldwide in the year 1990 (WHO study group 1994). The number of hip fracture patients continues to rise, due to a combination of an increasingly elderly population and an increase in the age specific incidence. A prediction for global numbers of 6.26 million hip fractures by the year 2050 has been made (Melton 1993). The majority of these fractures are treated surgically; thus hip fracture surgery represents one of the most common emergency orthopaedic procedures. Surgical treatment may be either fixation of the fracture or replacement of the femoral head with an arthroplasty. Internal fixation involves using screws or pins, either alone or in combination with a side plate applied to the femur, or by the use of an intramedullary nail with a cross screw inserted into the femoral head. Arthroplasty involves excision of the fractured area of bone and replacement with a partial or total hip replacement, which may be cemented in place. General anaesthesia refers to the use of a variety of intravenous and or inhalation drugs to render the patient unconscious. The patient may breathe spontaneously or require mechanical ventilation following the administration of neuromuscular blocking agents. Potential complications of general anaesthesia include adverse reactions to the drugs used, difficulty in maintaining or establishing

an airway, intra-operative hypotension, aspiration of gastric contents, post-operative nausea, respiratory depression and damage to the teeth or upper airways. Regional (also termed spinal) anaesthesia for hip fracture surgery refers to the injection of a local anaesthetic into the epidural or subarachnoid space at the lumbar spine. In some cases the patient also receives sedatives whilst the block is inserted and possibly during the surgery itself. The main complication of a regional technique is intra-operative hypotension, which may lead to cerebrovascular or myocardial ischaemia or infarction. Other problems may be an inadequate regional block, the rare complications of damage to local structures and headache secondary to leakage of cerebrospinal fluid from the dural puncture site. Specific advantages of regional anaesthesia may be a reduction in the incidence of thrombotic episodes and a reduced operative blood loss. These may be a consequence of an increased peripheral limb blood flow in combination with reduced venous tone. Alternatively they may arise from an alteration of blood viscosity and coagulability, as a result of changes in the metabolic and neurohumoral responses to surgery (Modig 1983). Other forms of anaesthesia used for hip fracture surgery are the insertion of local nerve blocks around the hip. These may be supplemented with sedatives, analgesics or other parental drugs. A lumber plexus block refers to injection of a local anaesthetic agent into the area of the lumbar plexus close to the transverse process of the forth lumbar vertebrae (Winnie 1974). Only the plexus on the side of the fracture needs to be blocked, which may reduce the incidence of complications such as operative hypotension. A sacral plexus block refers to the injection of a local anaesthetic agent in the area around the sacral nerves (Mansour 1993). The use of nerve blocks pre-operatively or in conjunction with general anaesthesia is considered in another Cochrane review (Parker 2001). An alternative type of anaesthetic involves the use of intravenous ketamine on its own. Ketamine renders the patient unconscious, thereby acting as a general anaesthetic, and has analgesic effects. No consensus exists as to which is the best method of anaesthesia. Currently the choice of anaesthesia used for hip fracture surgery
2

Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

Published by John Wiley & Sons. following assessment of the patient’s medical state. Unless otherwise stated. General anaesthesia using intravenous or inhalation agents to render the patient unconscious.hypotension (intra-operative or immediately post-operative) . In a meta-analysis.secondary intervention required for anaesthetic complications . inhalation general anaesthesia. Trials testing other methods of anaesthesia as the primary method of anaesthesia were considered for inclusion.damage to the upper airways or mouth from general anaesthesia . Sorensen 1992 concluded that the superiority of one method over the other was unproven. There is no difference in outcome between anaesthesia using ketamine (with or without a benzodiazepine) and inhalation general anaesthesia. 4. some trial data from two studies were duplicated in the analysis. Regional anaesthesia (if necessary supplemented by sedatives) achieved by injection of local anaesthetic into the epidural or subarachnoid spaces. 3.length of hospital stay (in days) b) Complications specific to the method of treatment: . This type of anaesthesia is also referred to as ’spinal’ or ’epidural’. were considered for inclusion. of 11 randomised trials of regional versus general anaesthesia for surgical repair of hip fractures. alternation).is determined by the personal preference of the anaesthetist concerned. Local nerve blocks (if necessary supplemented by sedatives) when used as the primary method of anaesthesia. Quasi-randomised trials (for example. There is no difference in outcome between regional anaesthesia (spinal or epidural) and general anaesthesia. are evaluated in another Cochrane review (Parker 2001). namely regional (either spinal or epidural).length of operation (in minutes) . Intravenous ketamine.need for supplementary drugs to complete anaesthetic (new in second update) . Ltd . Trials comparing the use of local nerve blocks in conjunction with general anaesthesia and the use of nerve blocks pre-operatively. 4. Types of intervention 1.any other adverse effects as detailed in each study (new in second update) c) General post-operative complications: (unless otherwise specified. local nerve blocks and intravenous ketamine anaesthesia were compared.operative blood loss (in millilitres) . In addition.changes in body temperature . using Bayesian methods. moreover.pneumonia 3 OBJECTIVES To determine the optimum anaesthetic technique for hip fracture surgery. Also not considered in this review were trials comparing different types of drugs or techniques of individual methods of anaesthesia. 6 months and 1 year). or by post-mortem) . the definition for these complications will be as detailed in each study. Variations in anaesthetic drug dosage and delivery or supplementary regional blocks were not considered within this review. Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. 2.pre and post-operative arterial blood gases . A more recent meta-analysis of randomised trials for all types of surgery has demonstrated a reduction of early post-operative mortality and morbidity with epidural or spinal anaesthesia (Rodgers 2000).aspiration pneumonia .intra-operative cardiac arrhythmias . 2. 3 months. and trials in which the treatment allocation was inadequately concealed. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW Types of studies All randomised controlled trials comparing different methods of anaesthesia were included. A general review of anaesthesia for hip fracture surgery (Covert 1989) summarised the possible advantages of different anaesthetic methods using information from eight of the randomised trials on this subject. 3. data were sought from each study for outcomes in the following categories. The following null hypotheses were tested within the trials included so far in this review: 1. a) Peri-operative outcomes: .time to mobilisation . Types of participants Skeletally mature patients undergoing hip fracture surgery. There is no difference in outcome between regional anaesthesia (spinal or epidural) and regional nerve blocks alone. general anaesthesia refers to general anaesthesia using inhalation agents in this review. Not all currently available randomised trials were included and. Different types of anaesthesia. There is no difference in outcome between regional anaesthesia (spinal or epidural) supplemented with a ’light’ general anaesthetic and general anaesthesia alone.changes in catecholamines and other stress response chemicals during and after surgery . Types of outcome measures The primary outcome measure was mortality (at 1 month.transfusion requirements/fall in haemoglobin .post-dural puncture headache .

5. In addition each trial was assessed without masking Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. giving a maximum score for each study of 11. Were the inclusion and exclusion criteria clearly defined? Score 1 if text states type of patients included and those excluded. The main assessment was by the quality of concealment of allocation which was scored either A.renal failure . ultrasound or phlethysmography. 3. A further eight aspects of methodology were used. or 3. relative risks and 95 per cent confidence limits have been calculated instead of Peto odds ratios 4 SEARCH STRATEGY FOR IDENTIFICATION OF STUDIES See: search strategy We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2000). were coded as C and scored 0. age. were coded as B and scored 1.urine retention (requiring catheterisation) . otherwise score 0. and checked by at least one of the other two reviewers. 9. Those in which allocation concealment was not stated.mortality (primary outcome) . otherwise score 0. Published by John Wiley & Sons. numbered sealed opaque envelopes drawn consecutively) were coded as A and scored 3. Ltd .deep vein thrombosis (diagnosis confirmed by post-mortem. 1. mobility. Those in which there was a possible chance of disclosure of assignment were coded as B and scored 2. function score. Any differences were resolved by discussion between the reviewers. 4.cerebrovascular accident . fracture type.post-operative nausea and /or vomiting . exp Anesthesia/ 5.functional status . ((an?esthet$ or an?esthesia) adj4 (regional$ or local$ or general or spinal or epidural)). ASA grade. 2. In MEDLINE (OVID WEB) the following search strategy was combined with the first two levels of the optimal trial search strategy (Clarke 2000).congestive cardiac failure . B or C according to the criteria in the Cochrane Reviewers’ Handbook (Clarke 2000). exp Hip Fractures/ 2. Were the care programmes other than trial options identical? Score 1 if text states they were. otherwise score 0. and/3. Were the outcome measures clearly defined in the text? Score 1 if yes. In accordance with the revised statistical policy of the Cochrane Musculoskeletal Injuries Group. Was the timing of outcome measures appropriate? This was considered to be a minimum of three months follow-up for all surviving patients. whether this was performed routinely or only as clinically indicated) . angiography or post-mortem) d) Final outcome measures: . mental test score). otherwise score 0.g. 1. 6.. otherwise score 0. 2.cardiac arrhythmias . 8. or if text states that no withdrawals occurred. Those where allocation concealment was clearly not concealed. Were the outcome assessors blind to treatment group? Score 1 if yes.tw. 6. isotope scanning. or/4-5 7. otherwise score 0. 1 or 0 as described below (item 1). or unclear. Was loss to follow-up reported and if so were less than five per cent of patients lost to follow-up? Score 1 if yes.6 Articles of all languages were considered and translated if necessary.myocardial infarction . such as trials using quasi-randomisation (e. announced in March 2000. otherwise score 0. Were the outcomes of patients who withdrew or were excluded after allocation described and included in an intention to treat analysis? This particularly applies to patients allocated to regional anaesthesia where it was not achieved due to technical difficulties. MEDLINE (1996 to December Week 4 2000) and reference lists of relevant articles.acute confusional state .change in mental function . otherwise score 0. METHODS OF THE REVIEW Data for the outcome measures listed above were independently extracted by two reviewers. even or odd date of birth). Trials with clear concealment of allocation (e. Score 1 if these patients were either detailed separately or included in the analysis group to which they were allocated. Heterogeneity between comparable trials was tested using a standard chi-squared test. sex.pulmonary embolism (diagnosed by isotope scanning. Were the treatment and control groups adequately described at entry? Score 1 if a minimum of four admission details were given (e. Score 1 if yes.g.return of patient to their pre-fracture place of residence for its quality of methodology. 7.((hip$ or femur$ or femoral$ or trochant$ or pertrochant$ or intertrochant$ or subtrochant$ or intracapsular$ or extracapsular$) adj4 fracture$). venography.g. or/1-3 4. 3.tw.

Ungemach 1993) being only available as conference abstracts. Seventeen included trials involving 2305 patients compared spinal or epidural anaesthesia with general anaesthesia. A further group of 20 patients in this study were allocated to receive a psoas nerve block in conjunction with general anaesthesia. Published by John Wiley & Sons. further details supplied by another trialist indicated that all the references applied to one study. is considered separately. Mean differences and 95 per cent confidence limits have been calculated for continuous outcomes. The one trial (Wajima 1995) in Studies Awaiting Assessment awaits translation from Japanese. The results for the random effects model are presented when there is significant heterogeneity in the results of individual trials. Two newly included studies compared spinal anaesthesia with nerve blocks (de Visme 2000. which is outside the scope of this review but included in another Cochrane review on localised nerve blocks (Parker 2001). Both Peto odds ratio and relative risk plots were viewed and a note was taken of where there was statistically significant heterogeneity (P< 0. one again which focused on a sub-group of patients monitored for deep vein thrombosis. Any tests of interaction. are based on odds ratio results. two were not randomised trials. Of the 15 excluded studies. Ungemach 1993) were included in this second update. two (Tonczar 1981. One study (White 1980) of 40 patients. METHODOLOGICAL QUALITY Treatment allocation was considered to be definitely concealed (Cochrane code A) in only one study (McKenzie 1984). Four references. Further details of the individual trials are given in the Characteristics of Included Studies table. Though these at first appeared to be reports of separate trials. were available for McKenzie 1984. Allocation concealment was possible (Cochrane code B) in a further five studies (Brown 1994. did not provide any results for the spinal versus general anaesthesia comparison. Wickstrom 1982) involved neuroleptic general anaesthesia which was considered to be no longer appropriate for hip fracture surgery. which was considered not to have direct clinical relevance. Eyrolle 1998. the four exceptions (Brichant 1995. Additional information on trial methodology and results would be welcomed from the authors of any of the studies. The remaining trial (Spreadbury 1980) compared ketamine anaesthesia with inhalation general anaesthesia in 60 patients.and 95 per cent confidence limits for dichotomous outcomes. and one (Dyson 1988) with a factorial design which focused on a comparison outside the review scope. Ltd . The 21 included trials involved a total of 2484 predominantly female and elderly hip fracture patients. de Visme 2000. Allocation was not concealed in the only overtly quasirandomised trial (Adams 1990) which allocated treatment by the date of operation. or from authors of trials which have not been identified. 37 studies were identified of which 21 trials were included in this review. one (Darling 1994) only reported one outcome. Eyrolle 1998). eight involved comparisons outside the scope of this review. 15 were excluded and one remains in Studies Awaiting Assessment. Translations were obtained for three trial reports in French and one in German. as well as the 14 studies which did not provide any details. the rate of clearance of injected indocyanine green. Maurette 1988. Further details of these are given in the Characteristics of Excluded Studies table. Results of comparable groups of trials were pooled using fixed and random effects models and 95 per cent confidence limits.1) using either method. The methodology scores using the scoring system described earlier were: REGIONAL VERSUS GENERAL ANAESTHESIA 1 2 3 4 5 6 7 8 9 Total (maximum 11) ————————————0 0 0 1 0 0 0 0 1 2 Adams 1990 1 1 0 1 1 1 1 1 0 8 Berggren 1987 1 1 0 1 1 1 1 1 0 7 Bigler 1985 1 1 0 1 1 1 0 0 1 6 Bredahl 1991 1 1 0 0 0 1 1 0 0 4 Brichant 1995 2 1 0 1 0 1 0 0 1 6 Brown 1994 1 1 0 1 1 1 0 0 1 6 Davis 1981 2 1 0 1 0 1 0 1 0 6 Davis 1987 1 1 0 1 1 1 1 0 0 6 Juelsgaard 1998 2 1 0 1 0 1 0 0 1 6 Maurette 1988 1 0 0 1 0 1 0 0 1 4 McLaren 1978 3 0 0 0 0 1 0 1 1 6 McKenzie 1984 2 1 0 0 1 1 0 1 1 7 Racle 1986 1 0 0 0 0 1 0 0 0 2 Tasker 1983 1 0 0 0 0 0 0 0 0 1 Ungemach 1993 1 1 0 1 0 1 1 1 1 7 Valentin 1986 5 Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. In all. Two trial reports were available for Davis 1981. one of which focused on a sub-group of patients monitored for deep vein thrombosis. Racle 1986) which gave incomplete details of their methods of randomisation. Couderc 1977. Seventeen trials were published as full reports in peer-reviewed journals. the study of Juelsgaard 1998 was included. Eyrolle 1998. Tasker 1983. DESCRIPTION OF STUDIES Three new studies (de Visme 2000. which used sealed envelopes and random numbers. calculated to determine if the results for subgroups were significantly different. A request has been sent to the contact author for further details of the study. which compared a ’light’ general anaesthetic in conjunction with spinal anaesthesia versus general anaesthesia. one (El-Zahaar 1995) involving a mixed population of orthopaedic patients did not provide separate data for hip fracture patients. In the first update.

as stated in the protocol. but not statistically significant when using the random effects model (RR 0. Additional mortality data were obtained for McKenzie 1984 from another trialist. The extent of assessor blinding was usually limited to select outcomes in most of the trials scoring on this item. The reduced mortality for regional anaesthesia at one month (53/781 (6. REGIONAL VERSUS GENERAL ANAESTHESIA Mortality Mortality was reported in most studies.41). The results are presented using the fixed effects model except where there is statistically significant heterogeneity between study results (P < 0. 95% confidence interval (CI) 0.1 to 8. or for under one month were provided by four studies (Adams 1990.81 to 1. or because an intention to treat analysis was not done. Valentin 1986). thrombosis. data for mortality up to one. Data for three months and beyond were extracted from graphs for two studies (Davis 1987.’LIGHT’ GENERAL ANAESTHESIA COMBINED WITH SPINAL ANAESTHESIA VERSUS GENERAL ANAESTHESIA 1 2 3 4 5 6 7 8 9 Total ————————————1 1 0 1 0 1 0 0 0 4 White 1980 REGIONAL (SPINAL) ANAESTHESIA VERSUS LOCAL NERVE BLOCKS 1 2 3 4 5 6 7 8 9 Total ————————————2 1 0 1 1 1 0 0 1 7 de Visme 2000 1 0 0 0 0 0 0 0 1 2 Eyrolle 1998 KETAMINE VERSUS GENERAL ANAESTHESIA 1 2 3 4 5 6 7 8 9 Total ————————————1 1 0 1 1 0 0 0 1 5 Spreadbury 1980 Two items meriting specific comment are items 3 (intention to treat) and 7 (assessor blinding). RR 0.72. 95% CI 0.33) and 12 months (80/354 (22.8%) versus 115/651 (16. Ungemach 1987).04. White 1980). Ungemach 1987). Bigler 1985. which provided data on deaths during hospital stay or under one month. with only the two largest trials (McKenzie 1984. One study had a non-significant increase for general anaesthesia (Bredahl 1991) and three studies found no difference between the two groups (Davis 1981. either because no information was available for patients withdrawn from the study or because those who had been withdrawn or excluded were not included in the baseline or outcome analyses. Brichant 1995. deep vein Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.92.07. 95% CI 0. where appropriate data were available. Other outcomes: a) Peri-operative outcomes Length of operation Most studies that recorded this outcome reported a statistically non-significant increase in the time taken to complete the operation for regional anaesthesia (Adams 1990. Other outcomes are presented in the categories listed under Types of outcome measures. the relationship is usually not an exact one and some conditions.6 minutes). such as operative hypotension. were pooled with the data for one month mortality (see analysis). Brown 1994. There was a similar pattern when the results from the three studies (Adams 1990. McKenzie 1984.8%) versus 78/826 (9. for these four pre-specified time periods. Bigler 1985.21).47 to 1. and pooled. body temperature and arterial blood gases. Since the primary outcome for this review. but slightly greater at six months (103/613 (16.12). is mortality. six and twelve months were deduced or extracted from study reports. Thus the results of such outcomes are not accurate guides of ’hard’ clinical outcomes and may be misleading. whose primary foci were body temperature.1%).71 to 1. such as peri-operative hypotension. except for four shortterm studies (Bredahl 1991. summarised in the analysis tables. Where possible. Berggren 1987.8 minutes. Pooling of data from six studies showed a statistically significant increase of around five minutes for regional anaesthesia (weighted mean difference 4. these include surrogate or intermediate outcomes. Ltd . The difference in mortality between the two groups was smaller and not statistically significant at subsequent follow-up times. Mortality at three months appeared marginally less in the regional anaesthesia group (86/726 (11. this is considered first. Tasker 1983. 95% CI 0. without providing denominators. The data for the first two studies. Maurette 1988).73.6%) versus 78/372 (21. which were for early deaths during hospital stay. oxygen saturation and psychological evaluation respectively. may be remedied to reduce the risk of a serious clinical event occurring. Published by John Wiley & Sons. that the difference in mortality was not statistically different between the two groups (4 versus 6). Tasker 1983 reported. Racle 1986). three.8%).00).4%)) was of borderline statistical significance when evaluated using the fixed effects method (relative risk (RR) 0.8%) versus 98/765 (12. Juelsgaard 1998. The number of trials and associated data for pooling shrank at each time interval.1) where the random effects model is applied. RR 1. Although such outcomes may be predictive of important clinical outcomes. Hypotension 6 RESULTS The outcome measures listed earlier were extracted for each study and. Maurette 1988. RR 1.51 to 1. Bigler 1985. No trial satisfied the criteria for the first item. which were at two weeks. Valentin 1986) contributing to the 12 month analysis. Mortality data for undefined follow-up periods.82 to 1.0%). 95% CI 1. 95% CI 0. and those for Ungemach 1987. were pooled with those for one month in an extra analysis. Results for all these studies are shown in the analyses tables.

respiration. Brown 1994. Davis 1981 reported that the general anaesthesia group showed a post-operative fall in oxygen saturation in the early post-operative period.09 to 1. Valentin 1986 reported a median stay of 10 days for regional anaesthesia and 11 days for general anaesthesia. who recorded body temperatures of 30 patients. McKenzie 1984) contained data for blood gases taken either pre-operatively. operatively or post-operatively.2 days. Davis 1987 reported an average of 16 days for both groups.40 to 1. Bigler 1985 reported the mean falls in haemoglobin to be greater in the regional anaesthesia group (22% versus 19%. two studies (Couderc 1977. P < 0. 20 days for both groups. 95% CI -40 to 322ml).and post-operative arterial blood gases The reports of six studies (Berggren 1987.87 to 1. Davis 1981. Maurette 1988. 95% CI 0. found significantly lower oxygen saturation for the group who received general anaesthesia. Juelsgaard 1998. Juelsgaard 1998 reported statistically non-significantly lower mean values of blood volume transfused over the operative and peri-operative period for the regional anaesthesia group (237ml versus 257ml). which was not seen after regional anaesthesia. but not when adopting the random effects model (RR 1.31. Davis 1981. Although this may reflect the different definition of hypotension in this trial. Berggren 1987 stated there was no difference in length of hospital stay between the two groups.58). that the drop in systolic blood pressure was significantly greater in the regional anaesthesia group. shown in the analysis tables. Adams 1990 and Juelsgaard 1998 reported a non-significant increase in blood loss for regional anaesthesia.63. An exploration of the effect of removing each of the trials in turn from the analysis revealed that the removal of the data from Couderc 1977 produced the most homogeneous result (chi-square = 0. McKenzie 1984 reported a significant decrease in the oxygen saturation at one hour post-operatively in those who received general anaesthesia compared with those who received regional anaesthesia. Maurette 1988. McKenzie 1984) show a statistically non-significant increase in operative blood loss for general anaesthesia (weighted mean difference 81ml. Summation of the two studies which quoted standard deviations (McKenzie 1984. Valentin 1986). Bigler 1985 reported no significant difference in the maximum drop of systolic blood pressure (48 versus 51mmHg). serum catecholamine and endocrine levels (Adams 1990. Berggren 1987 reported numbers of patients with post-operative arterial oxygen tension of less than 60mmHg and these are presented in an analysis table (10/28 (36%) versus 14/29 (48%).08).01) in the trial results and the pooled result was not statistically significant (weighted mean difference 141ml.3%) versus 68/120 (56. which are presented as either the numbers of patients who were transfused in three studies (Adams 1990.74. not significant). 95% CI 1.38). demonstrated no difference in the length of hospital stay between groups (weighted mean difference -0. 7 Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.28. RR 1. Ltd . Davis 1981). P = 0. McLaren 1978.2 to 4. McLaren 1978. Davis 1987.8%) versus 125/461 (27.60) which is more probably more appropriate given the significant heterogeneity of trial results (chi-square = 11. Pooling of data from eight studies (Berggren 1987. 95% CI -5. In contrast the transfusion requirements were greater in the regional anaesthesia group but there was significant heterogeneity (chi square = 12. Other peri-operative outcomes Other peri-operative outcomes recorded were changes in body temperature (Bredahl 1991). 95% CI -53 to 216ml). Ungemach 1993 used a scoring system which included level of consciousness. Tasker 1983). 40mmHg fall (Couderc 1977). Published by John Wiley & Sons.1%). Racle 1986). Five other studies contained insufficient data to enable pooling. and Racle 1986. Davis 1981) stated. Racle 1986) showed hypotension to be more common after regional anaesthesia. McLaren 1978) reported no difference in the mean arterial oxygen or carbon dioxide tensions for the two types of anaesthesia. Bigler 1985. 33 per cent fall (Juelsgaard 1998). Juelsgaard 1998 observed that the results for hospital stay were affected by a lack of rehabilitation facilities. in a study of post-operative oxygen saturation in 20 patients. Two studies (Adams 1990. concluded that temperature changes during the peri-operative period were unrelated to the type of anaesthesia. RR 0. Racle 1986). Bredahl 1991. Finally. Couderc 1977. This difference was statistically significant when viewed using the Peto fixed effects method (158/441 (35. Transfusion requirements Seven studies gave data for blood transfusion. and 20 per cent fall from the baseline in three studies (Davis 1987. circulation. Maurette 1988. In contrast. and Valentin 1986 reported a significantly increased blood loss in the general anaesthesia group. Pre. ECG changes (Juelsgaard 1998) and time to ambulation (Bigler 1985. was a greater than: 30 per cent reduction in systolic blood pressure (Berggren 1987). without data for pooling. or the mean volume of blood transfused (transfusion requirement) (Couderc 1977.6%)). Racle 1986). McKenzie 1984 recorded a mean of 38 days for regional anaesthesia against 43 days for general anaesthesia. Couderc 1977. Brown 1994. Brown 1994. Similar proportions of patients received transfusion in each group in the first three studies (63/108 (58.8 days). Length of hospital stay Most studies reporting this found no difference in the length of hospital stay. Adams 1990 reported 21 days for regional versus 20 days for general anaesthesia. By the first post-operative day there was no significant difference between the two groups.18.32). McLaren 1978 reported no significant difference. Juelsgaard 1998. Ungemach 1987 reported no difference. Operative blood loss Pooled data for three studies (Bredahl 1991. 95% CI 0.The definition of hypotension. blood loss and laboratory tests. there are too many other reasons to be certain that this is the case. when stated.

in one person in the spinal anaesthesia group was noted in Bigler 1985.6%) versus 12/477 (2. Summation of results in the analysis table demonstrated no difference between anaesthetic techniques (2/382 (0. The treatment of these spinal anaesthesia failures in the analyses presented by these three trials has further implications regarding intention to treat analysis. Racle 1986). Racle 1986). Summation of the results from five trials showed a non statistically significant reduction in myocardial infarction in the regional anaesthesia group (5/446 (1. Berggren 1987.22 to 3. and lastly. Acute confusional state This complication was reported in three small studies (Berggren 1987. A persistent headache.49 to 2.6%). Davis 1981. Cerebrovascular accident This complication was reported in seven studies (Berggren 1987. Myocardial infarction This complication was reported in six studies (Couderc 1977. Juelsgaard 1998. The eight patients in Davis 1981 were incorrectly analysed in the general anaesthesia group.Adams 1990 reported raised serum adrenaline and noradrenaline levels at the end of the operation for a sub-group of 32 patients. but it was not clear by how much and how this was manifested. RR 1. McKenzie 1984.7%). 95% CI 0. Pooling of results demonstrated a tendency to a lower risk with general anaesthesia but the difference was not statistically significant (10/529 (1. To reflect this. Couderc 1977. McKenzie 1984. RR 0. McLaren 1978 reported that there were no post-anaesthetic headaches.05. Pneumonia Pneumonia or ’chest infection’ was reported in nine studies (Adams 1990. Davis 1981. 95% CI 0. These have been included under the complication of pneumonia. in trial reports.1%) in Davis 1981 and in 30 out of 259 patients (11.64 to 3. Racle 1986).1%). Urine retention 8 Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.2%) versus 31/581 (5. it may be that the excluded patients had different characteristics and outcomes than those patients in which spinal anaesthesia was successful.7%). b) Complications specific to the method of treatment Davis 1981 was the only study to report on aspiration pneumonia. Pooling of data gave similar results for both groups (12/454 (2. the rise in levels being greater in those patients who received a general anaesthetic.1 days after general anaesthesia. Davis 1987. Juelsgaard 1998.86. Davis 1981.99. Summation of the limited results showed a non statistically significant reduction in the regional anaesthesia group (10/83 (12.9%) versus 6/556 (1. Post-operative scores in Ungemach 1993 were reported as ’better’ in the spinal group. RR 1. Post operative cardiac arrhythmia More abnormal cardiac rhythms were detected in the general anaesthesia group in Couderc 1977. reported a significantly greater increase in plasma noradrenaline and cortisol levels after general anaesthesia in comparison with regional anaesthesia. 95% CI 0. There was no report of intra-operative cardiac arrhythmias.3%). For instance.6%) in Davis 1987. Davis 1987. lasting three days. Davis 1987). was reported in both studies conducted by Davis et al (Davis 1981. Bigler 1985 reported a significant reduction in the mean time from surgery to ambulation of 3. Racle 1986).53. was unsuccessful in eight out of 72 patients (11. the data from fatal events have been sub-grouped separately from those listed as complications. Juelsgaard 1998 reported a significant increase in the overall number of ST segment depressions for those in the spinal anaesthesia group (125 versus 16 events). whereas the 30 patients in Davis 1987 were analysed in the spinal anaesthesia group. Davis 1987. c) General post-operative complications Data for most of the life threatening complications such as pneumonia.5%).1%) versus 8/471 (1. Davis 1987. Bigler 1985. Racle 1986). with two cases in the general anaesthesia group. Racle 1986).07).85). RR 0. Bigler 1985. usually resulting in the secondary use of general anaesthesia.51. Bigler 1985. RR 0. Davis 1981. 95% CI 0.3 days after regional anaesthesia versus 5. often performed by junior staff.0%) versus 19/84 (22. Bigler 1985.26 to 1.62 to 1. Tasker 1983. Valentin 1986 however reported no difference in the time to ambulation for patients in the two groups. Davis 1981. Renal failure Renal failure was reported in four studies (Adams 1990.59). Davis 1987 also referred to a 10% failure rate in the study of Valentin 1986. Berggren 1987. Failure of spinal anaesthesia. McKenzie 1984. 95% CI 0. Pooling of the results indicates no clear difference between the two anaesthetic methods (29/554 (5. or not wholly associated with deaths. RR 0.70. myocardial infarction. in a study of 100 patients. congestive cardiac failure and pulmonary embolism were only available as causes for deaths in many of the trial reports. McLaren 1978.57).27 to 1. these included results for other peri-operative changes in the cardiogram. Valentin 1986 chose to exclude them from the analysis.23). cerebral vascular accident. 95% CI 0.5%) versus 3/414 (0.41). Congestive cardiac failure This complication was reported in seven studies (Adams 1990. However. Couderc 1977 reported that there was no difference in the overall electrocardiographic results. Spinal anaesthesia. Published by John Wiley & Sons. There was no mention within the included studies of other complications such as damage to the upper airways or mouth from general anaesthesia. Davis 1987. Juelsgaard 1998. Ltd .

4%). Couderc 1977. include two deaths whose underlying cause was deep vein thrombosis from McLaren 1978.06). Maurette 1988) reported on long term changes in mental function. Brichant 1995. The source of heterogeneity resides mainly in the significantly different results in trials presenting solely results for fatal pulmonary embolism.12 to 3. 95% CI 0. supplementary intravenous propofol sedation was performed when necessary. McKenzie 1984). No patients died within the one month follow-up period of the study. The mean length of operation was 58 minutes in both groups.3%) versus 3/49 (6. McLaren 1978.37 to 2. RR 0.64. McLaren 1978) reporting this complication again showed similar results for the two anaesthetic techniques (2/46 (4. Racle 1986) but mostly as a reason for death rather than through active monitoring for non-fatal pulmonary embolism. REGIONAL (SPINAL) ANAESTHESIA VERSUS LOCAL NERVE BLOCKS Two studies.6%). based on Peto odds ratio results: P = 0.47 to 2. Complications reported were pneumonia (4 versus 5 cases). Post-operative vomiting Pooling of the data from the two studies (Bigler 1985. confusional states (3 in each group). Bigler 1985. Significantly fewer thromboses were detected in patients in the regional anaesthesia group (39/129 (30%) versus 61/130(47%). Patients in Brichant 1995 also received thromboembolic prophylaxis with low molecular weight heparin and anti-embolism stockings. The other study (de Visme 2000) compared spinal anaesthesia with a lumbar plexus block in conjunction with a sacral plexus block and iliac crest block (for lateral cutaneous nerve of the thigh). Composite outcome Ungemach 1993 used a scoring system which included complications such as heart failure. these results have to be viewed with caution since these were the results of subgroups of patients for whom data from venography or fibrinogen were available.48 to 0. Though the difference in incidence rates was consistent between trials. Changes in mental function Two studies (Bigler 1985. the patients specially monitored for deep vein thrombosis were also subgroups of the trial populations in two studies (Davis 1981.4%) versus 10/609 (1.02.70. but not for the return of patients to their previous residence. Maurette 1988 performed psychological evaluations on 33 patients and found no significant difference relating to the type of anaesthesia.85. fibrinogen update or at post-mortem. McKenzie 1984). Bigler 1985) reporting this complication showed similar results for the two anaesthetic techniques (10/48 (20. P = 0.94). Pooling the results from nine studies using Peto odds ratios showed statistically significant heterogeneity (chi-square = 14. In turn. were included. Berggren 1987. Deep vein thrombosis Deep vein thrombosis was the primary outcome for one study (Brichant 1995). McKenzie 1984) and fibrinogen scanning in Davis 1987. which presents these grouped by fatal and non- fatal pulmonary embolism. 95% CI 0. A second analysis. Pooled data. Davis 1981. 95% CI 0.98. RR 1. Published by John Wiley & Sons. with various prophylactic interventions being deployed: Dextran 70 (Berggren 1987).64).1%). 95% CI 0.23). deep vein thrombosis (1 in the general anaesthesia group) and post-operative vomiting (1 in each group). as well as cardiopulmonary evaluation and laboratory tests. and for two subgroups of patients from a further two studies (Davis 1981. Pulmonary embolism Pulmonary embolism was reported in ten studies (Adams 1990. where there is less fatal but more non-fatal pulmonary embolism in the regional anaesthesia group. There was no significant difference in the mean post-operative blood oxygen or carbon dioxide levels between the two groups.86). thrombosis and apoplexy. RR 0. No difference between the two groups was found in the scores at two weeks. Only McKenzie 1984 provided limited data on the location of patients at 12 months. grouped by method of diagnosis. Bigler 1985 reported that there was no persistent impairment in mental function. shows a contrasting and unexplained picture for these two outcomes (test for interaction. Awareness of the risk of deep vein thrombosis was evident in several other studies who did not report this outcome. heparin and active movement (Racle 1986) and antiembolic stockings (Valentin 1986). RR 0. McKenzie 1984.004). and no significant differences between the two groups in the mental scores achieved at three months.8%) versus 10/49 (20. involving 79 patients. One study (Eyrolle 1998) compared spinal anaesthesia with a lumbar plexus block in 50 patients. Summation of results from nine studies using the random effects model to allow for this heterogeneity showed little difference in overall incidence of pulmonary embolism in the two groups (8/575 (1. Venography screening was used to detect deep vein thrombosis in two studies (Brichant 1995.Pooling of the data from the two studies (Berggren 1987. and those presenting results for non-fatal pulmonary embolism. ’LIGHT’ GENERAL ANAESTHESIA COMBINED WITH SPINAL ANAESTHESIA VERSUS GENERAL ANAESTHESIA The only study (White 1980) in this category involved only 20 patients in each group. anti-vitamin K and early mobilisation (Couderc 1977). Intravenous alfentanil or sedatives were also used if necessary. whether measured by venography. d) Final outcome measures Mortality has already been considered above. Both studies only reported on outcome during the peri-operative period and did not report on 9 Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. early mobilisation (Bigler 1985). Results for most of these outcomes are presented in the analysis tables. Ltd . Functional outcome No study reported on the difference in functional outcomes between groups. Davis 1987.

in particular regarding concealment of allocation. RR 6. 95% CI 4. requiring repeated sedation that was judged as unsatisfactory. these are consistent with up to a 30 per cent reduction (95% CI 0. In both trials. DISCUSSION REGIONAL VERSUS GENERAL ANAESTHESIA Many of the studies within this review involved small numbers of patients and reported only a few outcome measures. similar numbers of patients had impaired cognitive function in de Visme 2000 (5/14 versus 6/15). KETAMINE VERSUS GENERAL ANAESTHESIA The only study included in this category (Spreadbury 1980) involved 60 female patients. In Eyrolle 1998. in the nerve block group (0/14 versus 5/15). Spreadbury 1980 reported that the differences were not statistically significant. there is a reasonable agreement between trials for many of the outcome measures reported. were more common in the spinal group in Eyrolle 1998 (6/25 versus 1/25. 95% CI -1. Post-operatively. The trial reports of all studies indicated a poor level of methodological rigour. this was reflected in the comparable mini-mental test scores (mean 15. Regional anaesthesia may reduce short-term mortality. RR 6. who considered that VAS rating for pain was unsatisfactory when there were cases of “sensorial” deficiency. either due to later dislocation of the prosthesis or an unstable fixation. 10 Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Insertion difficulty was significantly more common in the spinal group in Eyrolle 1998 (10/25 cases versus 3/25). The mean fall in arterial blood pressure was also significantly greater in the spinal group in de Visme 2000 (mean difference 16mmHg. including five cases of urinary retention. No cases of incomplete or unsatisfactory anaesthesia in the spinal group were reported in de Visme 2000 as opposed to four cases of incomplete anaesthesia and one case.5). They stated however that the dreams were more likely to be unpleasant after general anaesthesia.78 to 46.71 to 1. The proportions of patients who returned home were similar (19/30 versus 20/30). significantly higher doses of ephedrine were used to stabilise blood pressure in the spinal group (weighted mean difference 5. The high mortality within this group of patients often results from these other medical conditions rather than being a direct consequence of the hip fracture and its treatment.50). Inexperience with the anaesthetic techniques could be inferred in some studies. The three month mortality results retain a potential for a reduction in mortality in the regional anaesthesia group.10 to 0. the mean time to administer the spinal was reported as being statistically significantly lower in the spinal group in de Visme 2000 (12 versus 18 minutes. the need for supplementary sedation was significantly less in the spinal group (5/39 versus 24/40.46 to 7. The mean length of hospital stay for the 39 patients who returned home was 36 days for the ketamine group against 24 days for the general anaesthesia group. 95% CI 0. The limited results available are summarised in the analysis tables. Ltd . Spreadbury 1980 also reported the incidence of unsatisfactory surgical results. Despite these limitations.96mg.5 versus 14. Hip fractures occur predominantly in the frail elderly who have multiple other medical conditions. assessor blinding and intention to treat analysis.post-operative complications or mortality.21). Data were presented for early deaths (within 14 days) and late deaths (time unspecified. There were 7/30 (23%) such cases for the ketamine group against 3/30 (10%) for general anaesthesia. there was a high failure rate of spinal anaesthesia. A fall in mean arterial blood pressure of more than 20 per cent occurred in significantly more patients in the spinal group (18/25 versus 3/25. of the anaesthetists. yet this finding is borderline in that it is statistically significant when using the fixed effects model but not with the random effects model.3 to 30. reported p = 0. There is no evidence of substantial differences between regional and general anaesthesia in terms of long-term mortality.29). However. Results where available and appropriate are given in the analysis tables. No adverse effects of the techniques were reported by de Visme 2000. Adverse effects. Published by John Wiley & Sons. It remains possible that some of the differences in outcome within the studies could be related to the differences in the experience.00. Spreadbury 1980 also reported that the numbers of patients who experienced dreams and hallucinations were similar for the two groups (4 versus 5 patients). For example. the need for propofol supplementation. and competence. Pain as measured by the visual analogue scale (VAS) was stated as showing no difference between groups in Eyrolle 1998.02 to 17. of dosage greater than 1mg/kg/hr.013). RR 0.45mg).23. 95% CI 2. in hospital). often performed by junior staff.7mmHg). of over 11 per cent in both Davis 1981 and Davis 1987.0. In contrast. Eleven patients failed to complete VAS in de Visme 2000. there was no evidence that the seniority of the anaesthetists applying the different methods of anaesthesia differed in any given trial. particularly for mortality. This difference is statistically significant and is related to the higher incidence of unsatisfactory surgical results in the ketamine group (see below). congestive cardiac failure (2 cases) and pulmonary embolism (3 cases) were all derived from causes of death for the seven early deaths. Although the general anaesthesia group mobilised more quickly than the ketamine group. which subsequently required bed rest or traction. 95% CI 0.83) in Eyrolle 1998. Data presented for the complications of myocardial infarction (1 case). was significantly less common in the spinal group (5/25 versus 19/25). These showed no difference in the overall mortality during hospital stay (9/30 (30%) versus 9/30 (30%)). Overall.

more cerebrovascular accidents and less fatal pulmonary embolism but more non-fatal pulmonary embolism. available from two trials of poor methodology. orthopaedic. although unconfirmed. In addition. but the time taken for a regional anaesthesia is slightly longer. Published by John Wiley & Sons. It would not be unexpected that changing one aspect of hip fracture treatment (the type of anaesthesia) did not substantially affect long-term mortality. Regional anaesthesia is cheaper with respect to drug costs incurred during the administration of the anaesthetic. Whilst appropriate. Although there were fewer cases of acute confusion when regional anaesthesia was used. more evidence is required to draw valid conclusions. Potentially. we also consider that there is an important lack of longer term outcome data. The only key difference 11 Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. operations with regional anaesthesia were found to take approximately 5 to 10 minutes longer than general anaesthesia. has already been mentioned (see start of Results). regional anaesthesia could enable the group of very frail elderly to survive the initial surgery. Bigler 1985. KETAMINE VERSUS GENERAL ANAESTHESIA The sole trial (Spreadbury 1980) comparing ketamine with general anaesthesia involved only 60 patients. the increased blood flow to the lower limbs with alterations in coagulability and viscosity of the blood. as demonstrated by the results. Regional anaesthesia results in vasodilatation of the lower limbs and this results in an increased tendency to operative hypotension. Racle 1986. However. there are insufficient data to confirm this in this review and the care that needs to be taken in the interpretation of surrogate outcomes. Some possible. It was notable that over half the trials with at least 10 deaths per trial involved patients with hip fracture. As would be expected from clinical practice. Juelsgaard 1998 specifically targeted patients with known coronary artery disease. This may be due to the time taken to administer the regional anaesthesia and then the time taken for the analgesic effect to occur. no individual study had numbers large enough to determine if any difference exists. It is also possible that thromboembolic prophylaxis may have been withheld in those receiving regional anaesthesia in some studies. There was no difference between techniques for any of the outcome measures reported. No attempt was made at a cost evaluation within any of the trials. Eyrolle 1998) involved only 79 patients in total. In addition there was incomplete reporting of outcomes and no follow-up of patients. It is possible that the benefits of the reduced thromboembolic complications may be negated if thromboembolic prophylaxis is used. REGIONAL (SPINAL) ANAESTHESIA VERSUS LOCAL NERVE BLOCKS The two included trials (de Visme 2000. Valentin 1986). Pooled results for deep vein thrombosis showed a statistically significant reduction in the incidence of deep vein thrombosis in the regional anaesthesia group. This should not be considered conclusive as the data were from subgroups of patients who had been ’selected’ by their compliance with a method of diagnosis. Because of the small numbers of patients involved. Couderc 1977. In their comprehensive review of regional anaesthesia. such as hypotension. and thus the effect. In fact. may be the reason for the reduced incidence of venous thrombosis. The limited results available suggest that the local nerve blocks are associated with a reduced risk of operative hypotension but have a greater risk of incomplete or unsatisfactory analgesia. This may result in a predisposition to an increased incidence of cerebrovascular complications as hypotension is one of the aetiological factors for this complication. no conclusions about the lack of difference between the two techniques can be made. Rodgers et at (Rodgers 2000) found that post-operative mortality up to 30 days was significantly reduced for all types of surgery (general. these results are far from complete. only for death to ensue later from other medical complications. our conclusions are phrased in a more tentative way than Rodgers et al imply and. Because of the limited information. ’LIGHT’ GENERAL ANAESTHESIA COMBINED WITH SPINAL ANAESTHESIA VERSUS GENERAL ANAESTHESIA The sole study to address this question (White 1980) involved only 20 patients in each group. Ltd . urological and vascular) and concluded that their findings supported a “more widespread use of neuraxial blockade [spinal / epidural anaesthesia]”. Rodgers 2000 considered that a lack of statistical power in individual trials and meta-analyses could be the principal reason for a conclusion that “neuraxial blockade had no important effect on mortality”. firm conclusions cannot be made for this outcome. may have been distorted. The effects of thromboembolic prophylaxis may also affect the incidence of thromboembolic complications. Like Rodgers 2000 we consider further research is warranted. Brichant 1995. the numbers of patients in the trial were too small to determine which type of anaesthesia is best for this specific patient population. and certainly the effect size. There was a tendency for more hypotension with regional anaesthesia. As much of the data for many of these complications was for fatal complications. means that we cannot exclude clinically relevant differences. although there is a lack of statistical power in our review. trends for regional anaesthesia were for less myocardial infarction. no conclusions can be made on the use of nerve blocks compared with spinal anaesthesia. The results do suggest a trend towards a reduced risk of thromboembolic complications with regional anaesthesia but. because of the small number of trials that reported this outcome and the heterogeneity of results. Because of the low incidence of many of the complications following surgery.although the small numbers of patients with long-term followup. The routine use of thromboembolic prophylaxis was mentioned in six studies (Berggren 1987. thus enhancing the contribution of the findings of these trials to the overall result.

and long term outcomes. which related to a reduction in the risk of early fatal thromboembolic complications. This review was first updated in Issue 4. post-operative complications. SOURCES OF SUPPORT NOTES This review and first update was published under the title: “General versus spinal/epidural anaesthesia for surgery for hip fractures in adults”. ACKNOWLEDGEMENTS We would like to thank the following for useful comments from editorial review of the original review: Gordon Drummond (Department of Anaesthetics. Large trials with sub-group analysis may be able to determine if patients with specific medical conditions (such as cardiac disease. Tom Pedersen. The numbers of patients were too small to show if the increase in ’unsatisfactory surgical results’ in the ketamine group was a significant factor of ketamine use. Implications for research Well designed randomised trials. This included one trial (Ungemach 1993) comparing general versus spinal anaesthesia. Regional anaesthesia may be preferable for those patients at high risk for thromboembolic complications. However. of regional versus general anaesthesia involving large numbers of patients and which record. External sources of support • Chief Scientist Office. William Gillespie. We thank William Gillespie. REVIEWERS’ CONCLUSIONS Implications for practice Both regional and general anaesthesia produce comparable results and therefore the anaesthetists should choose which technique is most appropriate for each individual patient. William Gillespie. Leeann Morton. the primary clinical outcomes of death. with active follow-up of at least six months. Due to the limited data available. and the mortality during hospital stay was equal in both groups. Published by John Wiley & Sons. and two trials (Eyrolle 1998. A consumer synopsis was added and relative risks instead of Peto odds ratios were presented for dichotomous outcomes. There were no significant changes to the conclusions of the review. Ltd 12 . Gordon Murray. Janet Wale and Tony Wildsmith for their assistance and helpful feedback at editorial review. POTENTIAL CONFLICT OF INTEREST None known. Department of Health. University of Edinburgh). 2001. The trial search was updated to August 1999 and one small trial (Juelsgaard 1999) was included. 2000. For this update.was a reduction in the 14-day mortality for ketamine. at minimum. Leeann Morton and Lesley Gillespie for their help with the first update. previous stroke) are better managed with one of these two forms of anaesthesia. Peter Herbison. Tom Pedersen (Department of Anaesthesiology. The title was changed in the second update to reflect an expansion in the scope of the review to include comparisons of all forms of anaesthesia. Rajan Madhok. ketamine or spinal anaesthesia with ’light’ general anaesthesia for hip fracture anaesthesia. There were no significant changes to the conclusions of the review. we are indebted to Lesley Gillespie. The Scottish Office UK Internal sources of support • No sources of support supplied Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Copenhagen University Hospital) and Marc Swiontkowski. would help clarify the relative merits of regional and general anaesthesia. The second update appeared in Issue 4. this difference in mortality did not persist. de Visme 2000) which compared spinal anaesthesia with lumbar plexus blocks. it is not possible to determine the roles of nerve blocks.

35:54852. Lamy M. Sand NPR. British Journal of Anaesthesia 1995. [Abstract]. Couderc 1977 {published data only} Couderc E. et al. Davis 1987 {published data only} Davis FM. Frampton C. Quince M. [Comparative results of general and peridural anesthesia for hip surgery in the very old patient].59:1080-8. Legrand A. Brichant 1995 {published data only} Brichant JF. Brown 1994 {published data only} Brown AG. Bredahl 1991 {published data only} Bredahl C. Central neural blockage failed to decrease deep venous thrombosis in patients undergoing hip surgery and receiving low molecular weight heparin. Effects of anaesthetic technique on deep vein thrombosis: a comparison of subarachnoid and general anaesthesia. 66:497-504. Prospective. Analgesie. Smith G. Anesthesie.52:49-53. Laurenson VG. Smith G. Mauge F. Anaesthetic techniques for surgical correction of fractured neck of femur: a comparative study of spinal and general anaesthesia in the elderly. Buffels R. Changes in body heat during hip fracture surgery: a comparison of spinal analgesia and general anaesthesia. Comparative repercussions of general and spinal anesthesia on psychological functions of the aged subject [Repercussions comparees de l’anesthesie generale et de la rachianesthesie sur les fonctions psychiques du sujet age]. Vivier C. Smith G. [MedLine: 1982089249]. [MedLine: 89075140]. Acta Anaesthesiologica Scandinavica 1991. Maurette 1988 {published data only} Maurette P. Stockwell MC. Comparison of the effects of spinal anaesthesia and general anaesthesia on postoperative oxygenation and perioperative mortality.56:581-4. Regional anaesthesia for femoral neck fracture surgery: comparison of lumbar plexus block and spinal anaesthesia [Abstract]. [MedLine: 1991023367]. Wilkinson A. Long-term outcome after repair of fractured neck of femur. McKenzie PJ. Belbachir A. Petring OU.an audit of current practice. Anaesthesia and Intensive Care 1994. Postoperative course and endocrine stress response of geriatric patients with fractured neck of femur [Postoperativer verlauf und endokrine streb-reaktion geriatrischer patienten mit huftnahen frakturen. Anaesthesia and Intensive Care 1981. Irwins MG. [MedLine: 1985277121]. Busch P. Benkhadra A. [MedLine: 1987211148]. prospektiv-randomisierte studie zum vergleich von spinalanasthesin und halothan-intubatinosnarkosen]. BMJ 1981.80 Suppl 1:112. Anaesthesia 1978.281: 1528-9. [French] [Resultats comparatifs de l’anesthesie generale et peridurale chez le grand vieillard dans la chirurgie de la hanche]. Anasthesie. European Journal of Anaesthesiology 1998. Grant A.34(5):987-98. Reanimation 1977. Perioperative myocardial ischaemia in patients undergoing surgery for fractured hip randomized to incremental spinal.282:399-400.7:305-8. Anesthesia and Analgesia 1987. Wolf C. Erny P. Felsby S. Annales Francaises d’ Anesthesie et de Reanimation 1988. Dewar KMS. singledose spinal or general anaesthesia. [MedLine: 80198011]. Published by John Wiley & Sons. McKenzie PJ.9:352-8. Woolner DF. Visram AR.25(2):158-62. Bucht G. British Journal of Anaesthesia 1987. Berggren 1987 {published data only} Berggren D. Gustafson Y. Bacon-Shone J. Kalhke P. Gray I. McKenzie PJ. Eriksson B. multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly.33: 10-4. [MedLine: 1984203273]. comparison of subarachnoid and general anaesthesia.25:263-70. Hempelmann G. Conseiller C. Wishart HY. Bigler 1985 {published data only} Bigler D. Deep vein thrombosis and anaesthetic technique in emergency hip surgery. British Journal of Anaesthesia 1984. Le Jouan R. Winblad B. Jakobsen KB. Combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia for hip fractures in the elderly.REFERENCES References to studies included in this review Adams 1990 {published data only} Adams HA. 13 Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Davis FM. Gleizal B. McKenzie 1984 {published and unpublished data} McKenzie PJ. Reid VT. Postoperative confusion after anesthesia in elderly patients with femoral neck fractures. Wishart HY. Ltd . Blom-Peters L.15(6):656-63. ∗ McLaren 1978 {published data only} McLaren AD. Castagnera L. [MedLine: 1988024611]. Poy JY. Savry C. Dalsgaard J. Reiz S. Jones RDM.40:672-6. Spinal anaesthesia or general anaesthesia for emergency hip surgery in elderly patients. Racle 1986 {published data only} Racle JP. Gray I. de Visme 2000 {published data only} de Visme V.57:8537. Pederson NO. Harrison RT. Brink O. Desmonts J-M.74 Suppl 1:75. Hindsholm KB. Zetlaoui P. Wishard HY.5:24-30. Gaudray A. Juelsgaard 1998 {published data only} Juelsgaard P. [MedLine: 1991377412]. Hansson L-H. [MedLine: 81111251]. Anaesthesia for fractured neck of femur (letter). [MedLine: 1986213298]. [MedLine: 1978121768]. Regional Anesthesia and Pain Medicine 2000. Notfallmedizin 1990. Preoperative and postoperative oxygen saturation in the elderly following spinal or general anaesthesia . Wishart HY. Laurenson VG.22:150-4. Annales Francaises d’ Anesthesie et de Reanimation 1986. Intensivtherapie. Picard F. et al. Anaesthesia 1985. Duvaldestin P. Eyrolle 1998 {published data only} Eyrolle L. Davis 1981 {published data only} ∗ Davis FM. BMJ 1980. British Journal of Anaesthesia 1998. British Journal of Anaesthesia 1985. Frandsen PC. Rosencher N. Adelhoj B. [MedLine: 78185115]. [MedLine: 1985280155]. Michaelis G. [MedLine: 1994270545]. British Journal of Anaesthesia 1980. Comparative study of general and spinal anesthesia in elderly women in hip surgery [Etude comparative de l’anesthesie generale et de la rachianestesie chez la femme agee dans la chirurgie de la hanche]. Mental function and morbidity after acute hip surgery during spinal and general anaesthesia. Morin V.

Hammerle AF. Ungemach 1993 {published data only} Ungemach JW. Wickstrom 1982 Wickstrom I. Djiane V. Short TG. European Journal of Anaesthesiology. Sztark F.44(11):1489-97. References to studies excluded from this review Barna 1981 Barna B.78:706-9. Tasker 1983 {published data only} Tasker TPB. Changes in dementia rating scale scores of elderly patients with femoral neck fracture during perioperative period [Original in Japanese]. Anaesthesia 1980. Said AS. Kreiner S. Darling 1994 Darling JR.36:28891.16:405-10. Cosh PH. Chamley D. Anaesthesia and Intensive Care 1988. Additional references Clarke 2000 Clarke M. A comparison of 5 anesthetic methods. Assessment of study quality. Journal of Bone and Joint Surgery.10(5):380. Singer M. Petitjean ME. Anaesthesist 1987. The effect of isoflurane or spinal anesthesia on Indocyanine green disappearance rate in the elderly. An assessment of postoperative oxygen therapy in patients with fractured neck of femur. Anaesthesia 1980. Valentin 1986 {published data only} Valentin N. Anaesthesia 1994. Schoder K. Published by John Wiley & Sons. Tonczar 1981 Tonczar L. Ungemach 1987 Ungemach JW. Forster A. Hemodynamic effects of spinal anaesthesia in the elderly: single dose versus titration through a catheter. British Journal of Anaesthesia 1995. In: Review Manager (RevMan) [Computer program] Version 4. Ishikawa G. 68:276-81. [MedLine: 81083959]. Shitara T. Boyce WJ. References to studies awaiting assessment Wajima 1995 Wajima Z. Lomholt B. Crawshaw C. Anaesthesia 1982. A comparsion between lidocaine alone and lidocaine with meperidine for continous spinal anesthesia. Preliminary results of a prospective study (author’s translation) [Auswirkungen huftgelenksnaher operationen auf das verhalten von stressparametern und ihre beeinflussung durch anasthesie.Spreadbury 1980 {published data only} Spreadbury TH.74:373-8. El-Zahaar 1995 El-Zahaar MS. Hejgaard N. Anaesthesia for surgical correction of fractured femoral neck: a comparison of three techniques. Sutcliffe 1994 Sutcliffe AJ. Kohn RLJ. 58:284-91. Vorlaufige ergebnisse einer prospektiven studie].35:208-14. Journal of Neurological & Orthopaedic Medicine & Surgery 1995. Campbell ID. Favarel 1996 Favarel Garrigues JF. Anesthesia and Analgesia 1996. Surgical repair of hip fractures using continous spinal anaesthesia: comparison of hypobaric solutions of tetracaine and bupivaciane. Sinclair 1997 Sinclair S. Conway F. Mortality after spinal and general anaesthesia for surgical fixation of hip fractures. Kurosawa H. Anesthesia and Analgesia 1989. Masui 1995. Doxapram and the fractured femur.49:237-40. Spinal or general anaesthesia for surgery of the fractured hip? A prospective study of mortality in 578 patients. Anaesthetic techniques for surgical correction of fractured neck of femur: a comparative study of ketamine and relaxant anaesthesia in elderly women.315:909-12. Outcome after general anaesthesia for repair of fractured neck of femur: a randomised trial of spontaneous v. Raitt DG. 14 Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Holmberg I. Thicoipe M. et al. James S. Hainsworth AM. Subarachnoid block or general anaesthesia?: a study of the stress response during and after surgery for prosthetic replacement of fractured neck of femur. British Volume 1983. Anesthesia and Analgesia 1994.16(2):70-4. controlled ventilation. editors.18:290-5.122:1135-8. Comparison of spinal and general anesthesia in the surgical treatment of hip fractures [A spinalis es az altalanos anaesthesia osszehasonlitasa csipotaji toresek multejeinek erzesteleniteseben]. Al-Kawally HM. British Journal of Anaesthesia 1988. [MedLine: 1986131270].37:301-4. [Abstract].1. Erny P. Survival of female geriatric patients after hip fracture surgery.82:312-6. Stefansson T. Ltd . England: The Cochrane Collaboration 2000. The impairment of stress parameters by hip joint close operations and the influence of anaesthesia. Henderson AM. BMJ 1997. 1993. Hypotension during subarachnoid anaesthesia: haemodyamic effects of ephedrine. Coleman 1988 Coleman SA. Bonada G. Parker MJ. Regional Anesthesia 1993. Jensen JS. Eggert E. The role of anaesthesia in geriatric patients with hip fractures: A prospective study. Stuart JC.26:607-14. Dabadie P. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. Cochrane Reviewers’ Handbook 4. Lassie P. Yoshikawa T.7(3):138-41. McKenzie PJ. Orvosi Hetilap 1981. A double-blind randomized study of the effects of torniquet use and type of anesthetic techniques on the incidence of deep vein thrombosis (DVT) in orthopedic surgery. Hutton P. Gamulin Z. Inoue T. British Journal of Anaesthesia 1986. Vater M. Dyson 1988 Dyson A. Unfallchirurgie 1981. Murray JM. Chappell WA. Section 6. Trinick TR. Acta Anaesthesiologica Scandinavica 1982. Maurette 1993 Maurette P. White 1980 {published data only} White IW.1 [updated June 2000]. [MedLine: 1980218116]. Critchley 1995 Critchley LA. Inhalation anesthesia or “balanced anesthesia”? A comparative perioperative study in geriatric patients [Inhalationsanaesthesie oder “ balancierte anaesthesie ”?: Eine vergleichende perioperative studie geriatrischer patienten]. Owen 1982 Owen H. Oxman AD. Oxford.65:660.60:43-7. Andres FJ. Van Gessel 1989 Van Gessel EF.35:1107-10.

77: 1095-104. Parker 2001 Parker MJ. Borg T. British Journal of Anaesthesia 2000. Anesthesiology Reviews 1974. British Medical Journal 2000.during hospital stay Length of operation Hypotension Operative blood loss Transfusion requirements Length of hospital stay Blood levels of catecholamines. Oxford: Blackwell Scientific Publications. Role of extradural and of general anaesthesia in fibrinolysis and coagulation after total hip replacement. Durrani Z. Hip fracture management. WHO. lateral cutaneous. Fox GS. McKee A. Bone 1993.10. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.CD001159 Rodgers 2000 Rodgers A. Anaesthesia for hip surgery in the elderly. Bagge L. femoral. Sorensen 1992 Sorenson RM. Canadian Journal of Anaesthesia 1989. 3. Mean age 79/81 years (range 63-91).Covert 1989 Covert CR. Lefebvre C. Dickersin 1994 Dickersin K.1:11-6.1002/14651858. A meta-analysis. triple. van Zundert A. atropine Length of follow-up: period of hospital stay Mortality . Hip fractures: a worldwide problem today and tomorrow. ADH and adrenalin (see notes) 15 Interventions Outcomes Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Appadu BN. Ramamurthy S. Parker 1993 Parker MJ. Reevaluating the sciatic nerve block: another landmark for consideration. Schere R.36:311-9. British Journal of Anaesthesia 1983. 1994 WHO technical report series no. Germany 56 patients with a proximal femoral fracture. et al. WHO study group 1994 WHO study group. Parker MJ.Oxford: Update Software. In: The Cochrane Library. Nerve blocks (subcostal. 2001.55:625. Anesthesiology 1992. Plexus blocks for lower extremity surgery.5% bupivacaine and 4% mepivacaine versus General anaesthesia using thiopentone.309:1286-91.: 843 Winnie 1974 Winnie AP. Pryor GA. Griffiths R. Walker N. psoas) for hip fractures (Cochrane Review). Indicates the major publication for the study ∗ TABLES Characteristics of included studies Study Methods Participants Adams 1990 Quasi-randomised trial: by the date of operation Methodological score: 2 Orthopaedic hospital in Gieben.321:1493-7. Radonjic R. 1993. BMJ 1994. Schug S. Identifying relevant studies for systematic reviews. Modig 1983 Modig J. Pace NL. Published by John Wiley & Sons. Griffiths R. halothane. Mansour 1993 Mansour NY.18:322-3. vencuronium.14 Suppl 1:S1-8. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. References to other published versions of this review Urwin 2000 Urwin SC. nitrous oxide/oxygen. succinycholine. Melton 1993 Melton LJ III. Saldeen T.84(4):450-455. Male: 18% Number lost to follow-up: not stated Spinal anaesthesia using 0. Regional Anesthesia 1993. Kehlet H. Anesthetic techniques during surgical repair of femoral neck fractures. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials. Ltd .

adrenalin) results C Berggren 1987 Randomised trial: method not stated Methodological score: 8 Orthopaedic hospital in Umea. Sweden. suxemethonium. ventilated with nitrous oxide and oxygen and halothane and suxamethonium infusion.Characteristics of included studies (Continued ) Pneumonia (f ) Congestive cardiac failure (f ) Renal failure Pulmonary embolism (f ) Notes Allocation concealment Study Methods Participants Published in German Abstract and diagrams are contradictory for endocrine (ADH. Male: 17. 1 in the epidural group on 1st post-op day.5% Loss to follow-up: not known 16 Interventions Outcomes Notes Allocation concealment Study Methods Participants Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Length of follow-up: 12 months Mortality . Ltd . 57 patients with a femoral neck fracture Mean age 77/78 years (range 65-92 years). Male: 19% Number lost to follow-up: 4 (7%) Both groups premedicated with pethidine 25-50mg.data not presented. Published by John Wiley & Sons.5ml versus General anaesthesia with thipopentone 3-4mg/kg.1 year (see notes) Length of operation Operative hypotension Intraoperative blood loss (not split by treatment groups) Hypoxaemia Length of hospital stay Pneumonia Cerebrovascular accident Congestive cardiac failure Confusional state Urine rention Urinary tract infection Pulmonary embolism Total medical complications 4 died by 1 year. mean volume used 12. Spinal anaesthesia with 2% prilocaine in the epidural space. B Bigler 1985 Randomised trial: method not stated Methodological score: 7 Place and country of study not stated 40 patients with a proximal femoral fracture Mean age 79 years.5mg iv.25-0. Patients were interviewed at 6 and 12 months regarding living conditions and walking ability . the other 3 (group not given) by 5 months. atropine 0.

5% bupivacaine versus General anaesthesia using thoiopentane. nitrous oxide/oxygen. but 2 excluded due to incomplete data. Male: % not stated Number lost to follow-up: not stated Spinal (subarachroid or epidural) anaesthesia with bupivacaine 17 Outcomes Notes Allocation concealment Study Methods Participants Interventions Outcomes Notes Allocation concealment Study Methods Participants Interventions Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Denmark 30 female patients with a proximal femoral fracture Mean age 79 years (range 60-90).75% bupivacaine versus General anaesthesia using atropine. fentanyl. Belgium 106 patients with proximal femoral fracture Age: not stated. IPPV Length of follow-up: 3 days Length of operation Operative blood loss Change in body temperature (up to 3 hours) B Brichant 1995 Randomised trial: method not stated Methodological score: 4 Orthopaedic hospital in Brussels.Characteristics of included studies (Continued ) Interventions Spinal anaesthesia with 3ml of 0. Spinal anaesthesia with 2. Male: 0% Loss to follow-up: not stated. pancuronium. Published by John Wiley & Sons. nitrous oxide/oxygen Length of follow-up: 3 months Mortality . thoiopentane.early Length of operation Hypotension (maximum drop in systolic blood pressure) Transfusion requirements Fall in haemaglobin Pneumonia Cerebrovascular accident Congestive cardiac failure Confusional state Urine rention Post-operative vomiting Pulmonary embolism Time till ambulation Mental function Headache B Bredahl 1991 Randomised trial: method not stated Methodological score: 6 Orthopaedic hospital Aalborg. Ltd . pancuronium. pethidine.5-3ml of 0.

Male: 50% Number lost to follow-up: not stated Spinal (subarachnoid) anaesthesia with 0. pancuronium. Male: 14% Number lost to follow-up: not stated Spinal anaesthesia with 0.Characteristics of included studies (Continued ) versus General anaesthesia administered according to ’local practice’ Outcomes Length of follow-up: 10 days Deep vein thrombosis (venography) Pulmonary embolism Haemorrhagic complications Thrombocytopenia Conference abstract only All patients had subcutaneous nadroparin for DVT prophylaxis B Brown 1994 Randomised trial: use of random numbers table Methodological score: 6 Orthopaedic hospital in Hong Kong 20 patients with a proximal femoral fracture Mean age 77 years (range 66-91). 3 months Hypotension Transfusion requirements Oxygenation and carbon dioxide levels Myocardial infarction (f ) Cerebrovascular accident (f ) 18 Notes Allocation concealment Study Methods Participants Interventions Outcomes Notes Allocation concealment Study Methods Participants Interventions Outcomes Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. (Inclusion criterion: 80+ years. nitrous oxide/oxygen Length of follow-up: 3 months Mortality . isoflurane or enflurane and pre-medication with pethidine or temazepam Length of follow-up: 2 days (up to 44 hours) Hypotension Oxygen saturation B Couderc 1977 Randomised study: by ’drawing of lots’ Methodogical score: 4 Orthopaedic hospital in Paris. dextromoramide or methoxyflurane. Ltd .2mg/kg 0. France 100 patients with a proximal femoral fracture Mean age 86 years.5% bupivacaine versus General anaesthesia using thiopentone or propofol.11 days. Published by John Wiley & Sons. range not stated).5% bupivacaine and adrenaline versus General anaesthesia with thiopentone.

Fentanyl 1-3mcg/kg. but 11 excluded Spinal anaesthesia with sedation with diazapam.multicentre study 549 patients with a proximal femoral fracture Mean age 79. versus General anaesthesia with diazapam (2.Characteristics of included studies (Continued ) Pulmonary embolism (f ) Notes Allocation concealment Study Methods Participants In French Complete data for fatal myocardial infarction. Ltd .5% in 51 patients and 0. pancuronium mean dose 6mg.5mg. Results for DVT were available for 76 out of a sub-group of 90 patients who were monitored using I125 fibrogen scanning B Davis 1987 Randomised trial: method not stated Methodological score: 5 Orthopaedic hospitals in New Zealand .5-30mg) mean dose 9. nitrous oxide and oxygen. Male: 15% Number lost to follow-up: 0 Spinal anaesthesia using tetracaine 0. New Zealand 132 patients with a proximal femoral fracture Mean age 81/78 years (Inclusion criterion: 50+.5 years (range not stated). Tetracaine. Ketamine also used for sedation in 8 patients and diazapam (mean dose 9mg). range not given). nupercaine or bupivacaine for spinal versus 19 Interventions Outcomes Notes Allocation concealment Study Methods Participants Interventions Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.1 month Duration of anaesthesia (Length of operation) Postoperative blood gases Hypotension Operative blood loss Fall in haematocrit Pneumonia (f ) Aspiration pneumonia (f ) Myocardial infarction (f ) Cerebrovascular accident Congestive cardiac failure Renal failure Cardiac arrthymias Deep vein thrombosis (fibrinogen) Pulmonary embolism (f ) 8 failed spinals who had a general anaesthesia were placed in the general anaesthesia group. congestive heart failure and pulmonary embolism not provided. Length of follow-up : 1 month Mortality . B Davis 1981 Randomised trial: method not stated Methodological score: 6 Orthopaedic hospital Christchurch. Male: 22% Number lost to follow-up: 0.5% cinchocaine in 13 patients. IPPV. Published by John Wiley & Sons.

000 epinephrine. iv induction with thiopentone.Characteristics of included studies (Continued ) General anaesthesia with pre-oxygenation. 3 & 6 months (estimated from graph) Hypotension Length of hospital stay Pneumonia (f ) Myocardial infarction (f ) Cerebrovascular accident (f ) Congestive cardiac failure (f ) Renal failure (f ) Pulmonary embolism (f ) 11. Length of follow-up: not stated Ease of insertion Hypotension Use of propofol during surgery (associated with discomfort) Use of epinephrine during surgery Post-operative cognitive function Pain levels post-operatively Adverse effects (including urinary retention) Conference abstract only B Juelsgaard 1998 Randomised trial: method not stated Methodological score: 6 Orthopaedic hospital in Aarhus. These were retained in the spinal group for analysis purposes. France 50 patients with a proximal femoral fracture Mean age 82 years (range not stated) Male: % not stated Number lost to follow-up: none probably Spinal anaesthesia with 0.1 month.9 years (range 65-99) Male: 13% Number lost to follow-up: 0. There was 1 non fatal anaphylactoid reaction at induction of general anaesthesia B Eyrolle 1998 Randomised trial: method not stated Methodological score: 2 Orthopaedic hospital in Paris. Denmark 29 followed-up out of 54 patients with proximal femoral fracture and known coronary artery disease For 29 patients included in this review: Age: mean 80.3% of patients originally allocated to spinal anaesthesia were given general anaesthesia due to failed spinals. fentanyl Outcomes Length of follow-up: 3 to 30 months Mortality . Ltd . as required. IPPV maintained with nitrous oxide/oxygen. non-depolarizing neuromuscular blocker. but 11 excluded from original trial population 20 Notes Allocation concealment Study Methods Participants Interventions Outcomes Notes Allocation concealment Study Methods Participants Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. 0.5% bupivacaine versus lumber plexus block using 2% lidocaine. Published by John Wiley & Sons. A light sedation with propofol intravenously.5% bupivacaine with 1:200.

1 month Length of operation Hypotension (33% reduction from baseline) Peri and post operative blood loss Transfusion requirements Pneumonia (f ) Congestive cardiac failure (f ) Myocardial infarction ECG analysis Length of hospital stay The study also included 14 patients allocated to incremental spinal anaesthesia. enflurane. Ltd . Length of follow-up: 1 month Mortality . Male: % not stated Number lost to follow-up: not stated. 0. but 2 excluded as they failed to participate in post-op tests Spinal anaesthesia with 1. France 35 patients with a proximal femoral fracture Mean age 83 years (range not stated). nitrous oxide and oxygen. nitrous oxide/oxygen.3-1.5ml of 0. 1-4mg/kg thiopentone. Supplemented by small doses of diazapam if required versus 21 Outcomes Notes Allocation concealment Study Methods Participants Interventions Outcomes Notes Allocation concealment Study Methods Participants Interventions Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. but 2 excluded due to postponement of operation Spinal anaesthesia with 0. spontaneous ventilation.Characteristics of included studies (Continued ) Interventions Spinal anaesthesia with 2. Mean age 75 years (range not stated).5ml. enflurane. Male: % not stated Number lost to follow-up: 0.5% bupivacaine in the subarachnoid space versus General anaesthesia with fentanyl 1-2mcg/kg. Published by John Wiley & Sons.5mg/kg prilocaine versus General anaesthesia using thiopentone. These patients have not been included in this review B Maurette 1988 Randomised trial: by ’random draw’ Methodological score: 6 Orthopaedic hospital Bordeaux. dextromoramide Length of follow-up: 3 days Length of operation Hypotension Transfusion requirements Psychological evaluation In French B McKenzie 1984 Randomised trial: use of envelopes containing random numbers Methodological score: 6 Orthopaedic hospital in Glasgow.5% hyperbaric cinchocaine 1.5mg/kg atracurium. Scotland 150 patients with fractured neck of femur.

Number lost to follow-up: 0 No premedicaton Spinal anaesthesia with 0. nitrous oxide and oxygen. 6 and 12 months Length of operation Operative blood loss Length of hospital stay Pneumonia (f ) Myocardial infarction (f ) Cerebrovascular accident (f ) Deep vein thrombosis (venography) Pulmonary embolism (f ) Location at 12 months Additional information supplied by Dr McLaren indicated that all the references refered to one study.1 mg/kg.5%. Male: % not stated. versus General anaesthesia with Althesin 50mcg/kg. oxygen and Fentanyl 0.1 month Length of operation Hypotension Post-operative oxygenation Blood loss Pneumonia (respiratory infections) Vomiting Deep vein thrombosis (f ) Pulmonary embolism (f ) Headache (none) Addendum in paper indicated that data for a further 20 patients were available . IPPV. suxamethonium 50mg.5ml hyperbaric cinchocaine 0. Published by John Wiley & Sons. Outcomes Length of follow-up: 12 months Mortality .05mg as needed. Patients sedated with 10% Althesin in 5% dextrose during operation. Length of follow-up: 1 month minimum Mortality . 3. Scotland 55 patients with fractured neck of femur Mean age 76 years.there were 2 more deaths in the general anaesthesia group B Racle 1986 Randomised study: use of random numbers table 22 Notes Allocation concealment Study Methods Participants Interventions Outcomes Notes Allocation concealment Study Methods Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Additional data on mortality supplied.at 1. Ltd . Pancuronium bromide 0.Characteristics of included studies (Continued ) General anaesthesia induced with althesin 1-3ml. The venography study for DVT detection involved a subgroup of 40 patients A McLaren 1978 Randomised trial: method not stated Methodological score: 4 Orthopaedic hospital in Glasgow. nitrous oxide. halothane and spontaneous respiration.

14 days.6mg then a general anaesthetic using drugs and method chosen by the anaesthetist Length of follow-up: not stated Mortality .Characteristics of included studies (Continued ) Methodological score: 6 Participants Orthopaedic hospital in Cedex. enflurane Length of follow-up: 3 months Mortality . vecuronium. Male: 0% Number lost to follow-up: not stated Spinal anaesthesia with 3ml 0.1. 3 months Length of operation Hypotension Transfusion requirements Length of hospital stay Pneumonia Myocardial infarction Cerebrovascular accident (f ) Congestive cardiac failure Renal failure (f ) Confused state Pulmonary embolism In French B Spreadbury 1980 Randomised: method not stated Methodological score: 6 Orthopaedic hospital in Warwick. fentanyl. France. Ltd 23 . range not given). ketamine 2mg/kg at induction then ketamine 1mg/kg as required versus General anaesthesia using premedication of atropine 0. Male: % not stated Number lost to follow-up: none Ketamine anaesthesia using atropine pre-medication. England 60 female patients with a proximal femoral fracture Mean age 84 years (range not stated). Published by John Wiley & Sons. during hospital stay Myocardial infarction (f ) Congestive cardiac failure (f ) Pulmonary embolism (f ) Time to mobilisation Length of hospital stay Return of patients back home Occurrence of dreams or hallucinations after operation Unsatisfactory surgical results Interventions Outcomes Notes Allocation concealment Study Methods Participants Interventions Outcomes Notes Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. nitrous oxide/oxygen.5% Bupivacaine + adrenaline versus General anaesthesia using thiopentone. 70 female patients with a proximal femoral fracture Mean age: 82 years (Inclusion criterion: 75+.

Characteristics of included studies (Continued ) Allocation concealment Study Methods Participants B Tasker 1983 Randomised trial: method not stated Methodological score: 2 Orthopaedic hospital in Leicester. Male: 16% Number lost to follow-up: not stated Spinal anaesthesia with 3-4ml of 0. cardiopulmonary situation and complications (e. Ltd . fentanyl. Score based on lab tests. Male: 20% Number lost to follow-up: 2 (0.05-0.2 weeks Score based on conscious level. cortisol Conference abstract only B Ungemach 1993 Randomised trial: method not stated. nitrous oxide/oxygen Length of follow-up: 2 weeks Mortality . mention of pairs Methodological score: 1 Orthopaedic hospital in Mannheim. Mean age 79 years (range not stated). respiration. heart failure. England 100 patients with a proximal femoral fracture.1mg IV versus 24 Interventions Outcomes Notes Allocation concealment Study Methods Participants Interventions Outcomes Notes Allocation concealment Study Methods Participants Interventions Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. Published by John Wiley & Sons. 84 patients excluded Spinal anaesthesia with 3-4ml isotonic Bupivacaine and sedation with Fentanyl 0. thrombosis and apoplexy) at 2 weeks post-operatively Conference abstract only B Valentin 1986 Randomised trial: method not stated Methodological score: 7 Orthopaedic hospital in Hellerup.100). blood lost and laboratory tests taken at 2 hours. circulation. Germany 114 patients with a proximal femoral fracture.3%). Denmark 662 patients with a proximal femoral fracture Mean age 79 years (range 50 . Male: % not stated Number lost to follow-up: not stated Spinal versus general anaesthesia Exact method of anaesthesia not stated Length of follow-up: not stated Mortality Plasma catecholamines. Mean age not stated.5% hyperbaric bupivacaine versus General anaesthesia with isoflurane.g.

Ltd . nitrous oxide/oxygen. Mean age 79 years (range not stated). fentanyl and nitrous oxide/oxygen Outcomes Length of follow-up: 24 months Mortality . 6 and 12 months (read from graphs) Length of operation Operative blood loss Time to ambulation Length of hospital stay B White 1980 Randomised trial: method not stated Methodological score: 4 Orthopaedic hospital in Cape Town. France 29 patients with a proximal femoral fracture Mean age 85 years (range 68-97). fentanyl versus Psoas nerve block with 30ml 2% mepivacaine and ’light’ general anaesthesia with fentanyl and althesin (not included in review) Length of follow-up: minimum 4 weeks Mortality . nitrous oxide/oxygen versus General anaesthesia with thiopentone. suxamethonium.8ml hyperbaric cinchocaine and ’light’ general anaesthesia with althesin. Male: 17% Number lost to follow-up: none Spinal anaesthesia with sedation using alfentanil and 3ml 0.6-0.1 month Length of operation Post operative blood gases (oxygen and carbon dioxide) Pneumonia Confusional state Deep vein thrombosis Vomiting The 20 Psoas nerve block group patients were not included in this review B de Visme 2000 Randomised trial: method by ’hospital pharmacy before transfer to the operating theatre’ Methodological score: 7 Orthopaedic hospital in Brest. Published by John Wiley & Sons.1 month. 3. halothane. South Africa 40 of 60 patients in trial with a proximal femoral fracture. Male: 8% Number lost to follow-up: 0 Spinal anaesthesia with 0.5% plain bupivacaine for the spinal versus 25 Notes Allocation concealment Study Methods Participants Interventions Outcomes Notes Allocation concealment Study Methods Participants Interventions Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.Characteristics of included studies (Continued ) General anaesthesia with enflurane and nitrous oxide/oxygen with or without thiopentone at induction or neurolept anaesthesia with droperidol. fentanyl.

The trial was excluded as it was a trial of different drugs with the same anaesthetic technique. There was no difference in the rate of disappearance of the indocyanine green between the two techniques and no other outcomes were reported. The trial was excluded as it was not a trial of different types of anaesthesia but a comparison of different drugs within one form of anaesthesia. Published by John Wiley & Sons. or tibial surgery (97 patients). The study was excluded as there was no randomisation of patients. A randomised trial of 60 patients which tested the use of postoperative oxygen in two groups that had already been divided into those receiving general anaesthesia and those receiving spinal anaesthesia. The study was excluded as it involved a change in the types of drugs used only. 26 Critchley 1995 Darling 1994 Dyson 1988 El-Zahaar 1995 Favarel 1996 Maurette 1993 Owen 1982 Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. A randomised trial of 34 hip fracture patients comparing continous spinal anaesthesia with lidocanine alone versus lidocaine with meperidine. 30ml and 10ml of 1. A randomised trial of a single dose of doxapram on the post-operative arterial oxygen tension in hip fracture patients. A randomised trial of 30 hip fracture patients comparing spinal anaesthesia with ephedrine alone or with ephedrine and colloid. This study was a randomised comparison of general versus epidural anaesthesia in 214 patients undergoing either hip or femoral surgery (117 patients).lumber plexus. The trial was excluded due to the lack of outcome data for the anaesthesia comparison. A randomised trial of 60 hip fracture patients comparing the haemodynamic effects of a single dose of spinal bupivacaine versus a continuous titrated dose. The trial was excluded as it was not considered a comparison of different forms of anaesthesia. Outcome measures were the onset of anaesthesia and haemodynamic variables.33% lidocaine and epinephrine were used for the lumbar and sacral blocks and 5ml 1% lidocaine for the iliac crest block (for lateral cutaneous nerve). This trial was excluded because separate results for patients having surgery for a hip fracture were not presented. Outcomes Length of follow-up: not stated but probably 5 days Length of operation Time to perform the anaesthetic Hypotension Use of epinephrine during surgery Post-operative cognitive function Pain levels in the recovery room Need for supplemention of analgesia B Notes Allocation concealment (f ) = fatal: outcome such as pneumonia only appears as a reason for death Characteristics of excluded studies Study Barna 1981 Coleman 1988 Reason for exclusion Translation of the article from Hungarian revealed it is a comparative study of 100 spinal anaesthetics and 100 general anaesthetics for hip fracture patients. only of a modification of anaesthetic technique. not a change in the method of anaesthesia. The study was excluded as it was not felt relevant to this review as no clinical outcomes were reported. Ltd . A randomised trial of 152 patients comparing general anaesthesia with spontaneous respiration with general anaesthesia with controlled ventilation. The trial was excluded as it was not a comparison of anaesthetic techniques. sacral plexus and iliac crest block first with sedation using alfentanil. A randomised trial of 10 patients with spinal anaesthetic and 10 with general anaesthesia to assess the rate of clearance of a bolus dose of Indocyanine green between the two anaesthetic techniques. not a comparision of different types of anaesthesia. No results were provided for the anaesthetic comparison save the general statement that there was no statistical difference in mean oxygen tensions between the two anaesthesia groups.

A randomised trial of 14 patients comparing neuroleptic anaesthesia with spinal anaesthesia. cortisol. 53. Published by John Wiley & Sons. 4.74 [0.04 [0.76 [0.69 [-40. of studies 8 8 6 3 2 11 6 8 8 3 3 3 1 2 9 5 No. The trial was excluded as it was a comparison of different drugs within one type of anaesthesia (general anaesthesia) and not a comparison of different anaesthetic techniques.04] 4. 1.72 [0.92 [0.1 month 02 Mortality .82. 8.18 [0. A comparison of non-concurrent treatment groups was also not considered appropriate. This was a report of two quasi-randomised trials (based on dates of birth) with a month in-between.33] 1. 1. The first study was excluded as it was considered that neuroleptic anaesthesia was no longer applicable or relevant for hip fracture surgery. 1.82.09.56] 1. Ltd . The second study was excluded as it was a comparison of different drugs within one type of anaesthesia (general anaesthesia) and not a comparison of different anaesthetic techniques.07 [0. 1.01.87.99 [0.81.54] Relative Risk (Fixed) 95% CI 1.3 months 04 Mortality .60] Weighted Mean Difference (Random) 95% CI -81.73 [0.31 [1.21] 1.71. 321. The study was excluded as it was not a comparison of different types of anaesthesia.56.24] Weighted Mean Difference (Random) 95% CI 140. 1.33.78] Relative Risk (Fixed) 95% CI 0.51.12] 0.21. The study was excluded as it involved a neuroleptic anaesthesia and the only outcome measures were plasma catecholamines. The first study compared epidural versus ketamine intravenous infusion versus neurolept general anaesthesia in 129 hip fracture patients.71] Relative Risk (Fixed) 95% CI 0.41] 0. 1. A comparative study of 1333 patients with general versus spinal anaesthesia.1 month (random effects model) 03 Mortality .24 [-216.12 months 06 Mortality . Patients were randomised to have either conventional intra-operative fluid management or colloid fluid challenges.01 [0. 1.59] Relative Risk (Fixed) 95% CI 0.85] 27 Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.08.62. 1. 1.58] 1.82 [1.38] Weighted Mean Difference (Fixed) 95% CI -0. 1.early and up to 1 month 07 Length of operation (mins) 08 Operative hypotension 09 Operative hypotension (random effects model) 10 Operative blood loss (mls) 11 Patients receiving blood transfusion 12 Transfusion requirements (mls) 13 Post-operative hypoxia 14 Length of hospital stay 15 Pneumonia 16 Myocardial infarction No.6 months 05 Mortality .40.00] 0.Characteristics of excluded studies (Continued ) Sinclair 1997 A randomised trial of 40 patients with a hip fracture surgically treated under general anaesthesia. reported as one study. blood pressure and changes in heart rate. 1.21 [-5. Regional (spinal or epidural) versus general anaesthesia Outcome title 01 Mortality . 1. A randomised trial of 30 hip fracture patients comparing spinal anaesthesia with either hypobaric tetracaine or hypobaric bupivacaine.47. The trial was excluded as it was a not a trial of different types of anaesthesia but a comparison of different drugs within one form of anaesthesia. The study was excluded as there was no randomisation of patients.70 [0.26. The second study compared enflurane general anaesthesia versus halothane general anaesthesia in 40 hip fracture patients. of participants 1607 1607 1491 1264 726 1817 376 902 902 308 228 203 57 218 1125 917 Statistical method Relative Risk (Fixed) 95% CI Relative Risk (Random) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Weighted Mean Difference (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Random) 95% CI Effect size 0. A randomised trial of 50 hip fracture patients using either enflurane or enflurane and fentanyl. Sutcliffe 1994 Tonczar 1981 Ungemach 1987 Van Gessel 1989 Wickstrom 1982 GRAPHS Comparison 01.

14. Spinal.65] 12.00 [0. Anesthesia.69] 5. 2. 7. 30. Spinal and ’light’ general anaesthetic versus general anaesthetic Outcome title 01 Mortality .86 [0.50] 6. of participants 60 60 60 60 39 Statistical method Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Weighted Mean Difference (Fixed) 95% CI Effect size 1.01.05 [0.12.86] 0. 1. 3.47. 1.64 [0. 2.00 [1. Hip Fractures [∗ surgery]. Epidural.94] 0.07] 1. Ltd 28 . Conduction.70 [0. 4. 7.80 [0.25.00 [5.96 [4. 2.41] 0.00 [0.87] 0.35. Published by John Wiley & Sons.22.55] 1. of participants 40 40 40 40 40 Statistical method Relative Risk (Fixed) 95% CI Weighted Mean Difference (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Effect size Not estimable 0. Clinical Trials.94] 0.20 [0. Intravenous ketamine versus general anaesthesia Outcome title 01 Mortality .01. of participants 79 50 29 79 79 29 Statistical method Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Weighted Mean Difference (Fixed) 95% CI Weighted Mean Difference (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Effect size 0.72] Comparison 03.45] 6. 3.46.89.00] 0. of studies 2 1 1 2 2 1 No.23] 0.89 [0.83] 16. Randomized Controlled Trials Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.37.during hospital stay 02 Myocardial infarction 03 Congestive cardiac failure 04 Pulmonary embolism 05 Length of hospital stay (discharge home) No. Anesthesia.17] 0. of studies 1 1 1 1 1 No.33 [0. Postoperative Complications. 0.98 [0.29] 0. 2.23.43] INDEX TERMS Medical Subject Headings (MeSH) Adult.46.01.14 [0.57] 1. General. 2.27.42. 17. 3.64] Subtotals only Comparison 02.00 [-14.10.48. Length of Stay.1 month 02 Length of operation 03 Pneumonia 04 Confusional state 05 Deep vein thrombosis No. 2.51 [0. ∗ Anesthesia.31.00 [2. ∗ Anesthesia.37] 0.53 [0.78. 0.89] 0.01. 4.23 [0.02. 18.90 [0. 2. of studies 1 1 1 1 1 No.23] 0.02 [0. 7.28] Comparison 04.17 Cerebrovascular accident 18 Congestive cardiac failure 19 Renal failure 20 Acute confusional state 21 Urine retention 22 Vomiting 23 Deep vein thrombosis 24 Pulmonary embolism 25 Pulmonary embolism (random effects model) 26 Pulmonary embolism (fatal and non fatal) 7 7 4 3 2 2 4 9 9 1085 931 796 167 97 95 259 1184 1184 Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Fixed) 95% CI Relative Risk (Random) 95% CI Relative Risk (Fixed) 95% CI 1.49.57. 46. Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome title 01 Incomplete or unsatisfactory analgesia 02 Operative hypotension 03 Mean fall in arterial blood pressure (mmHg) 04 Mean dose of ephedrine used (mg) 05 Adverse effects 06 Post-operative confusion No.33 [0.64.00 [0.

The updates were compiled by MP and HH with RG independently extracting data. Griffiths R. Helen Handoll (HH) identified the trial studies. involved an expansion of the scope of the review to include comparisons of all forms of anaesthesia. The other two reviewers (HH and MP) independently checked these results and entered the review into RevMan. Published by John Wiley & Sons. Susan Urwin was not available to contribute to or comment on the second update. 1997/4 1999/4 06 August 2003 04 July 2001 Issue protocol first published Review first published Date of most recent amendment Date of most recent SUBSTANTIVE amendment What’s New The second update. All reviewers critically reviewed successive drafts of the review. one comparing general versus spinal anaesthesia (Ungemach 1993) and two (Eyrolle 1998. de Visme 2000) comparing spinal anaesthesia with lumbar plexus blocks. Three new trials were included.1002/14651858. first appearing in Issue 4.CD000521 CD000521 Cochrane Musculoskeletal Injuries Group HM-MUSKINJ 29 Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.MeSH check words Human COVER SHEET Title Authors Contribution of author(s) Anaesthesia for hip fracture surgery in adults Parker MJ. Ltd . 2001. Susan Urwin and Richard Griffiths independently assessed trial quality and extracted data. Handoll HHG. as reflected in the changed review title. Considerations of surrogate outcomes led to a slight amendment to the conclusions of the review. Information not supplied by author Date new studies sought but none found Date new studies found but not yet included/excluded Date new studies found and included/excluded Date authors’ conclusions section amended DOI Cochrane Library number Editorial group Editorial group code Information not supplied by author 01 March 2001 Information not supplied by author 10. Martyn Parker is the guarantor of the review. Urwin SC Martyn Parker (MP) initiated the review and wrote the first draft of the protocol.

41.05 0.1 month Study Regional n/N Berggren 1987 Davis 1981 Davis 1987 Juelsgaard 1998 McKenzie 1984 McLaren 1978 Racle 1986 Valentin 1986 Total (95% CI) 1/28 3/64 17/259 4/15 8/73 1/26 2/35 17/281 781 General n/N 0/29 9/68 16/279 2/14 13/75 9/29 5/35 24/297 826 Relative Risk (Fixed) 95% CI Weight (%) 0.75 [ 0.00 ] 01 Mortality .65 ] 0. 1.7 16.10 [ 0.7% Test for overall effect z=1.0 Relative Risk (Fixed) 95% CI 3.4 20.12 [ 0. 8. 0.25 ] 1. 2. 1. 78 (General) Test for heterogeneity chi-square=9.6 11.36 ] 0.35 [ 0. 1.93 ] 0.28.01 0.51.6 100.1 month Total events: 53 (Regional).25 I =22.44 ] 0.GRAPHS AND OTHER TABLES Comparison 04. 1.10.91 ] 0.59.8 11.1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.40.87 [ 0.63 [ 0. 1. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 01 Mortality .5 30.22 ] 1.08.14 [ 0.13.05 df=7 p=0.12 ] 0.40 [ 0.1 6.02.72 [ 0. Published by John Wiley & Sons.96 p=0.2 2. 73. Ltd 30 .

0.7 4.5 6.87 [ 0.25 ] 1.18 ] 0. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 03 Mortality . 73.0 Relative Risk (Fixed) 95% CI 3.73 [ 0.10. 1.7 24.46 p=0.40. 1.59 p=0.71.23.0 Relative Risk (Random) 95% CI 3.28.25 [ 0.97 [ 0.80 [ 0.4 100. Ltd 31 .12 ] 0.9 18.1 month (random effects model) Study Regional n/N Berggren 1987 Davis 1981 Davis 1987 Juelsgaard 1998 McKenzie 1984 McLaren 1978 Racle 1986 Valentin 1986 Total (95% CI) 1/28 3/64 17/259 4/15 8/73 1/26 2/35 17/281 781 General n/N 0/29 9/68 16/279 2/14 13/75 9/29 5/35 24/297 826 Relative Risk (Random) 95% CI Weight (%) 1.12 ] Total events: 53 (Regional).58 [ 0.40 [ 0.14 [ 0. 98 (General) Test for heterogeneity chi-square=4.12 [ 0. 73.1 0.47 I =0.08.0 17.01 0.35 [ 0.41.96 ] 0.5 12.Comparison 04.44 ] 0.12 ] 0.65 ] 0. 2. 1. 1.80.1 1 10 100 Favours regional Favours general Comparison 04.2 33.22 ] 1.1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.01 0.59 df=5 p=0. 1.10 [ 0. 78 (General) Test for heterogeneity chi-square=9.77 ] 0.42.36 ] 1.5 31. 2. Published by John Wiley & Sons.13. 1.6 0.10 [ 0.3 6.0% Test for overall effect z=0.75 [ 0.02.93 ] 0.47.59. 8.05 df=7 p=0.21 ] Total events: 86 (Regional).91 ] 0.3 months Study Regional n/N Berggren 1987 Couderc 1977 Davis 1987 McKenzie 1984 Racle 1986 Valentin 1986 Total (95% CI) 1/28 7/50 36/259 16/73 4/35 22/281 726 General n/N 0/29 12/50 31/279 17/75 5/35 33/297 765 03 Mortality .25 I =22.8 9. Review: Anaesthesia for hip fracture surgery in adults 02 Mortality .13.3 months Relative Risk (Fixed) 95% CI Weight (%) 0. 1.4 100.53. 1.73 ] 0.92 [ 0.36 ] 0.63 [ 0.25.1 month (random effects model) Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 02 Mortality .6 27. 1. 1.70 [ 0.4 5.7% Test for overall effect z=1.

1. 1.66 ] 0.13 [ 0.81. 1.07 [ 0.41 ] Total events: 80 (Regional).52 ] 1.6 20. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 05 Mortality . 1.12 months Relative Risk (Fixed) 95% CI Weight (%) 32.3 40.12 months Study Regional n/N McKenzie 1984 Valentin 1986 Total (95% CI) 26/73 54/281 354 General n/N 25/75 53/297 372 05 Mortality .0 Relative Risk (Fixed) 95% CI 1.1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.6 100.0 100.6 0.04 [ 0. 105 (General) Test for heterogeneity chi-square=0.4 67.47 ] 1.58. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 04 Mortality .Comparison 04.67 ] 1.01 0.6 months Study Regional n/N Davis 1987 McKenzie 1984 Valentin 1986 Total (95% CI) 44/259 20/73 39/281 613 General n/N 42/279 21/75 42/297 651 04 Mortality . Ltd 32 . 1.07 [ 0.30 df=2 p=0.65 ] 0.8 0. 78 (General) Test for heterogeneity chi-square=0.98 [ 0.00 df=1 p=0.1 1 10 100 Favours regional Favours general Comparison 04.82.0% Test for overall effect z=0.86 I =0.66.98 [ 0.77.98 I =0.01 0.0 Relative Risk (Fixed) 95% CI 1.69. 1. Published by John Wiley & Sons.31 p=0.6 months Relative Risk (Fixed) 95% CI Weight (%) 39.76.0% Test for overall effect z=0.51 p=0.08 [ 0. 1.33 ] Total events: 103 (Regional).

early and up to 1 month Study Regional n/N Adams 1990 Berggren 1987 Bigler 1985 Davis 1981 Davis 1987 Juelsgaard 1998 McKenzie 1984 McLaren 1978 Racle 1986 Ungemach 1993 Valentin 1986 Total (95% CI) 4/24 1/28 1/20 3/64 17/259 4/15 8/73 1/26 2/35 3/57 17/281 882 General n/N 3/32 0/29 1/20 9/68 16/279 2/14 13/75 9/29 5/35 3/57 24/297 935 Relative Risk (Fixed) 95% CI Weight (%) 3. Ltd 33 .76 [ 0.78 [ 0.65 ] 0.5 15. 14.75 ] 0.21 ] 3.6 2. 73.90 ] 0. 7.25 ] 1. 2. 1.1 100.07.0 Relative Risk (Fixed) 95% CI 1.56.59.1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. 1.41. 1.6 28.93 ] 1.02.40 I =5.13. Review: Anaesthesia for hip fracture surgery in adults 06 Mortality .5 10.01 0.63 [ 0.12 ] 1. 1.21.12 [ 0. 85 (General) Test for heterogeneity chi-square=10.52 df=10 p=0.28.35 [ 0.22 ] 1.2 10. 0.6 1.10.5 18.44.0% Test for overall effect z=1.1 0.3 6.00 [ 0.69 p=0. 1.40.early and up to 1 month Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 06 Mortality .44 ] 0. 4. Published by John Wiley & Sons.Comparison 04.36 ] 0.14 [ 0.04 ] Total events: 61 (Regional).00 [ 0.40 [ 0.09 0.91 ] 0.0 3. 8.87 [ 0.08.75 [ 0.10 [ 0.

90) 77. 2.39 ] 3.2 5.00) 59.3 0.58 ] Total events: 158 (Regional).10.8 7.4 7.00 (10.12 ] 5.00) 71.70 [ 0.90) 80.00 (22.70) 65. 1.01 Regional Mean(SD) 35.Comparison 04.11 [ 0.1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.88.82 p=0.82 [ 1.21. 1.0% Test for overall effect z=2.00 (44. Published by John Wiley & Sons.78.01 0. 1.00 [ -17.50 (20.3 100.20 (22. 2.09. 1.40 ] 1.79 I =0.005 0.00 [ -2.42 [ 0.35 [ 0.00 [ -21.9 2.65 ] 9.42 df=5 p=0. Ltd 34 .10 ] -5.50) N 29 20 13 15 75 35 187 General Mean(SD) 31.58 [ 1.98 ] 0.08 I =46.0 Favours regional Favours general Comparison 04.08 ] 9.2 52.0 0 5. Review: Anaesthesia for hip fracture surgery in adults 07 Length of operation (mins) Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 07 Length of operation (mins) Study N Berggren 1987 Bigler 1985 Bredahl 1991 Maurette 1988 McKenzie 1984 Racle 1986 Total (95% CI) 28 20 15 18 73 35 189 p=0. 33.5 21.8% Test for overall effect z=2.20) 125.12.00 (22.52 -10.50 (12.92. 20. 21.56 ] Test for heterogeneity chi-square=2.0 16.20 (27.43 [ 0.34 ] Not estimable 0.80) 82.04 ] 1.90) Weighted Mean Difference (Fixed) 95% CI Weight (%) 51.22 ] 1. 8.28 df=6 p=0.00 [ -3. 30.00 (10. 11.4 0.80) 60.65.40.00 (35.8 100.00 [ -1.0 9. 9.21 ] 1.92 ] 4.00) 67.5 9.6 5. 2.31 [ 1.00 [ -3.08.00 (5.0 Weighted Mean Difference (Fixed) 95% CI 4.08.00 (35. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 08 Operative hypotension Study Regional n/N Berggren 1987 x Brown 1994 Couderc 1977 Davis 1987 Juelsgaard 1998 Maurette 1988 McLaren 1978 Racle 1986 Total (95% CI) 18/28 0/10 14/50 98/259 12/15 3/18 3/26 10/35 441 General n/N 13/29 0/10 20/50 67/279 9/14 6/15 1/29 9/35 461 08 Operative hypotension Relative Risk (Fixed) 95% CI Weight (%) 10.19.0 -5.70) 116.51.37. 13.0 Relative Risk (Fixed) 95% CI 1.0 10.12. 125 (General) Test for heterogeneity chi-square=11.19 ] 8.24 [ 0.

30) 261.6% Test for overall effect z=1.0 Weighted Mean Difference (Random) 95% CI -131.22 ] 1.70) 468.00 [ -84.86 ] 16.1 28.1 1 10 100 Favours regional Favours general Comparison 04.04 ] 1. Published by John Wiley & Sons. 116.0 Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. -43.06 p=0.00 (432.34 ] Not estimable 0. Review: Anaesthesia for hip fracture surgery in adults 10 Operative blood loss (mls) Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 10 Operative blood loss (mls) Study N Bredahl 1991 Davis 1981 McKenzie 1984 Total (95% CI) 15 64 73 152 p=0.00 (232.40 ] 1.51.00 [ -284.37.88.35. Ltd 35 .43 [ 0.0 Relative Risk (Random) 95% CI 1.60 ] Total events: 158 (Regional). 1. 2.0 -500.8% Test for overall effect z=1. Review: Anaesthesia for hip fracture surgery in adults 09 Operative hypotension (random effects model) Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 09 Operative hypotension (random effects model) Study Regional n/N Berggren 1987 x Brown 1994 Couderc 1977 Davis 1987 Juelsgaard 1998 Maurette 1988 McLaren 1978 Racle 1986 Total (95% CI) 18/28 0/10 14/50 98/259 12/15 3/18 3/26 10/35 441 General n/N 13/29 0/10 20/50 67/279 9/14 6/15 1/29 9/35 461 Relative Risk (Random) 95% CI Weight (%) 18.8 10.89 ] -81.24 [ 0.40) N 13 68 75 156 General Mean(SD) 321.14.07 I =62.18 [ 0.80) Weighted Mean Difference (Random) 95% CI Weight (%) 18.08 I =46.40.00) 277.87.21 ] 1.42 [ 0.4 1.35 df=2 p=0.98 ] 0.00 (186. 1. 1.21. 1.39 ] 3.70 (308.0 Favours regional 0 500.00 [ -384.28 df=6 p=0.70 (317.18 -1000.0 19.54 ] Test for heterogeneity chi-square=5.0 16. 53.12.5 100.5 0. 125 (General) Test for heterogeneity chi-square=11.78.01.8 100.00) 304.00 (445. 2.24 [ -216.58 [ 1. 122.01 0.11 [ 0.Comparison 04.3 5.70 [ 0.2 Regional Mean(SD) 190.35 [ 0.7 42.35 ] -164.0 1000.3 0.89. 30. 2.8 38.

33 [ 0.00) 300.8 10. Ltd 36 .60 (282.00 (400.60 [ -126.0 Relative Risk (Fixed) 95% CI 1.0 -50.0% Test for overall effect z=0.2 32.33.63 df=2 p=0.00 (150.26.07 p=0.Comparison 04.78 ] 8.24 ] Total events: 63 (Regional).00) 600.69 [ -40.0 100.9 0.13 ] 1.75.92 [ 0. 68 (General) Test for heterogeneity chi-square=1.00 (292.01 [ 0.82.43 I =0.84 ] 1.67 df=2 p=0.60.77 ] 0.00 (300. 321.002 I =84.1 Regional Mean(SD) 1100.22.00) 488.00 (150.01 0.6 100.0 0 50.46 ] 140. 1. 2.00) 480.4 100.52 -100. 402.7 77.0 Weighted Mean Difference (Random) 95% CI 100.29 [ 0. Review: Anaesthesia for hip fracture surgery in adults 12 Transfusion requirements (mls) Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 12 Transfusion requirements (mls) Study N Couderc 1977 Maurette 1988 Racle 1986 Total (95% CI) 50 18 35 103 p=0.0 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.80) N 50 15 35 100 General Mean(SD) 1000. 238.70 ] Test for heterogeneity chi-square=12. Review: Anaesthesia for hip fracture surgery in adults 11 Patients receiving blood transfusion Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 11 Patients receiving blood transfusion Study Regional n/N Adams 1990 Bigler 1985 Davis 1981 Total (95% CI) 9/24 9/20 45/64 108 General n/N 9/32 7/20 52/68 120 Relative Risk (Fixed) 95% CI Weight (%) 11.1 1 10 100 Favours regional Favours general Comparison 04.59.2% Test for overall effect z=1.00 [ 197. Published by John Wiley & Sons.2 35.59 ] 300.63.80) Weighted Mean Difference (Random) 95% CI Weight (%) 32. 2.00 [ -38. 1. 143.

38 ] 0.0% Test for overall effect z=0. 1.3 0.30.01 0.78 ] Test for heterogeneity chi-square=0.0 -50. 5.1 1 10 100 Favours regional Favours general Comparison 04.38 ] Total events: 10 (Regional). 4.30) 20.08 -100.0 Relative Risk (Fixed) 95% CI 0.05 (11.0 0 50.1 93. Published by John Wiley & Sons. 16.40. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 14 Length of hospital stay Study N McKenzie 1984 Racle 1986 Total (95% CI) 73 35 108 p=0.20 ] -0.40) 14 Length of hospital stay Weighted Mean Difference (Fixed) 95% CI Weight (%) 6.0 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.10 ] 0.0 Weighted Mean Difference (Fixed) 95% CI -4. 14 (General) Test for heterogeneity: not applicable Test for overall effect z=0.95 p=0.70 I =0.50) 20.74 [ 0. 1.21.80 (55.10 [ -24.15 df=1 p=0.9 100.04 [ -5.Comparison 04.09 (10.90 (69.60) N 75 35 110 General Mean(SD) 42.12.74 [ 0.0 100.21 [ -5.0 100.40.9 Regional Mean(SD) 38. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 13 Post-operative hypoxia Study Regional n/N Berggren 1987 Total (95% CI) 10/28 28 General n/N 14/29 29 13 Post-operative hypoxia Relative Risk (Fixed) 95% CI Weight (%) 100. Ltd 37 .

80 ] 1.74 I =0. 20.08 ] 1. 1. 19 (General) Test for heterogeneity chi-square=3.99 [ 0.64 df=3 p=0.37.7 12. 31 (General) Test for heterogeneity chi-square=6.88 ] 1. 2.62.91 ] 1.73 02 Other (non fatal or fatal) Berggren 1987 Bigler 1985 McLaren 1978 Racle 1986 Subtotal (95% CI) 1/28 1/20 9/26 3/35 109 2/29 2/20 7/29 8/35 113 6.04 p=1 0.26 ] 0.50 [ 0. 2.6 26.79 Total (95% CI) p=0.30 I =17.40 ] 0.11.99 df=4 p=0.62. 12 (General) Test for heterogeneity chi-square=1.42.42. 89.30 ] 0. 3.10.63.6 0.71 [ 0. 4. 1.69 [ 0.01 0.4 544 581 100.5 Total events: 14 (Regional).96 ] 4.0% Test for overall effect z=0.43 [ 0.0% Test for overall effect z=0.6 1. Published by John Wiley & Sons.0 0.Comparison 04.1 60. 5.1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.24.05.52 [ 0. 5.7 39.8 12. Ltd 38 . 6.05.78 [ 0.74 ] Total events: 15 (Regional).6% Test for overall effect z=0.32 [ 0.7 9.4 1.4 6.53 [ 0.5 21.38 [ 0.09. 1.45 ] p=0.33 [ 0.35 [ 0.59 ] Total events: 29 (Regional).19 df=8 p=0.30 ] 0.63 I =0. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 15 Pneumonia Study Regional n/N 01 Fatal (reason for death only) Adams 1990 Davis 1981 Davis 1987 Juelsgaard 1998 McKenzie 1984 Subtotal (95% CI) 1/24 2/64 5/259 2/15 5/73 435 1/32 4/68 4/279 0/14 3/75 468 General n/N 15 Pneumonia Relative Risk (Fixed) 95% CI Weight (%) Relative Risk (Fixed) 95% CI 2.

2.53 ] 2.72 p=0.0 2.81 [ 0. 4.5 48.39 Total (95% CI) p=0.63 I =0.67 df=2 p=0. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 16 Myocardial infarction Study Regional n/N 01 Fatal (reason for death only) Davis 1981 Davis 1987 McKenzie 1984 Subtotal (95% CI) 0/64 2/259 0/73 396 1/68 1/279 2/75 422 General n/N 16 Myocardial infarction Relative Risk (Fixed) 95% CI Weight (%) Relative Risk (Fixed) 95% CI 15.21 [ 0.01. 2.12.0% Test for overall effect z=0.0% Test for overall effect z=0. 8 (General) Test for heterogeneity chi-square=2.0 0.5 0.7 446 471 100.20.34 I =0. 23. 8.5 10.62 ] 0.58 df=4 p=0.43 I =0.15.5 42.01. 1.83 ] 0.01 0.15 [ 0.35 [ 0. 4 (General) Test for heterogeneity chi-square=0. 63.2 52.2 26. Published by John Wiley & Sons. 4 (General) Test for heterogeneity chi-square=1.56 ] 0.50 [ 0.62 ] Total events: 2 (Regional).5 Total events: 3 (Regional).1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.10.63 [ 0.63 02 Other (non fatal or fatal) Juelsgaard 1998 Racle 1986 Subtotal (95% CI) 1/15 2/35 50 0/14 4/35 49 5. Ltd 39 .93 df=1 p=0.70 [ 0. 2.20.85 ] Total events: 5 (Regional).96 ] p=0.0% Test for overall effect z=0.76 [ 0.0 0.Comparison 04.21 ] 0.26.

1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.3 529 556 100.43 I =0.71 ] Total events: 5 (Regional).0% Test for overall effect z=0.53.3 0.01.10 df=6 p=0. 7. 6 (General) Test for heterogeneity chi-square=5.7 Total events: 5 (Regional). Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 17 Cerebrovascular accident Study Regional n/N 01 Fatal (reason for death only) Couderc 1977 Davis 1987 McKenzie 1984 Racle 1986 Subtotal (95% CI) 2/50 3/259 0/73 0/35 417 2/50 0/279 1/75 1/35 439 General n/N 17 Cerebrovascular accident Relative Risk (Fixed) 95% CI Weight (%) Relative Risk (Fixed) 95% CI 23.8 1.34 02 Other (non fatal or fatal) Berggren 1987 Bigler 1985 Davis 1981 Subtotal (95% CI) 3/28 0/20 2/64 112 0/29 1/20 1/68 117 5. 3.75 df=3 p=0.00 [ 0. Ltd 40 .2% Test for overall effect z=1. 8. 134.82 ] 7.07 [ 0.72 ] 2.01 0.24 [ 0. 145.7 17.06 ] p=0.8 11.20.33 [ 0.7 5.27 ] 0.15.2 7. 2 (General) Test for heterogeneity chi-square=2.34 [ 0.39.Comparison 04.8 17. 6. 3.64.0% Test for overall effect z=0.91 ] 1.37 I =0.13 [ 0.5 35.6 17.22 [ 0. 8.95 p=0. 4 (General) Test for heterogeneity chi-square=2.05 Total (95% CI) p=0.54 [ 0.40. Published by John Wiley & Sons.33 [ 0.51 [ 0.0 1.12 ] 0.01. 7.87 ] 2.01.24 ] 0. 22.57 ] Total events: 10 (Regional).00 df=2 p=0.53 I =0.8 64.39.

83 I =0.33 [ 0. Published by John Wiley & Sons.1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. 2.34 [ 0.9 0.08 [ 0. 2. 63.26.09.8 454 477 100.6 22.13 p=0.12.00 [ 0.05 [ 0.85 [ 0. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 18 Congestive cardiac failure Study Regional n/N 01 Fatal (reason for death only) Adams 1990 Davis 1987 Juelsgaard 1998 Subtotal (95% CI) 2/24 3/259 1/15 298 2/32 3/279 0/14 325 General n/N 18 Congestive cardiac failure Relative Risk (Fixed) 95% CI Weight (%) Relative Risk (Fixed) 95% CI 13.05.8 4. 5 (General) Test for heterogeneity chi-square=0.5 1. 7 (General) Test for heterogeneity chi-square=2.39 ] 0.54 I =0.85 df=6 p=0.18 ] 0.0% Test for overall effect z=0.07.83 ] 1. 15.15 df=3 p=0.0% Test for overall effect z=0.36 ] 0.80 ] 1.9 59.01 0. 2.9 9.87 I =0.40 ] p=0.29 ] 2.30.20.11 ] 1.49.4 38.43 [ 0.69 [ 0.30 Total (95% CI) p=0.81 [ 0. Ltd 41 . 10. 103. 5.6 Total events: 6 (Regional).Comparison 04.5 5.44.1 40.17 [ 0.0 1.4 7.10 ] Total events: 6 (Regional).22.23 ] Total events: 12 (Regional).51 02 Other (non fatal or fatal) Berggren 1987 Bigler 1985 Davis 1981 Racle 1986 Subtotal (95% CI) 2/28 1/29 2/64 1/35 156 0/29 1/20 5/68 1/35 152 3. 8.29 df=2 p=0. 4. 12 (General) Test for heterogeneity chi-square=2.0% Test for overall effect z=0.

21 p=0. 19 (Control) Test for heterogeneity chi-square=0. 1. 2 (General) Test for heterogeneity chi-square=0.19.00 [ 0.04 [ 0.01. Ltd 42 .01 0. 78.71 I =0.3 58. 5.33 [ 0.0% Test for overall effect z=0.95 ] 0.9 1.40 df=3 p=0.07.27.10.39 df=1 p=0. 7.15 ] Total events: 1 (Regional). 20.9 53.2 34.0 0.35 [ 0.1 1 10 100 Favours regional Favours general Comparison 04.13.45 [ 0. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 20 Acute confusional state Study Regional n/N Berggren 1987 Bigler 1985 Racle 1986 Total (95% CI) 4/28 1/20 5/35 83 Control n/N 7/29 1/20 11/35 84 20 Acute confusional state Relative Risk (Fixed) 95% CI Weight (%) 36.09.13 ] p=1 Total events: 1 (Regional).98 df=1 p=0.04 02 Other (non fatal or fatal) Adams 1990 Davis 1981 Subtotal (95% CI) 1/24 0/64 88 1/32 1/68 100 20.9 46.22. 1.32 I =0.72 [ 0.0% Test for overall effect z=1.01.86 [ 0.41 ] Total events: 2 (Regional).08 0. Published by John Wiley & Sons.1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.8 0.0% Test for overall effect z=0.91 ] 1. 8.26 ] 0. 14.17 ] 0.90 ] 0.18.80 ] 1.Comparison 04.84 I =0.0 33.33 Total (95% CI) p=0. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 19 Renal failure Study Regional n/N 01 Fatal (reason for death only) Davis 1987 Racle 1986 Subtotal (95% CI) 1/259 0/35 294 0/279 1/35 314 General n/N 19 Renal failure Relative Risk (Fixed) 95% CI Weight (%) Relative Risk (Fixed) 95% CI 11.01 0.53 [ 0. 1.1 3.3 100. 3 (General) Test for heterogeneity chi-square=1.59 [ 0.7 382 414 100.35 df=2 p=0.33 [ 0.4 5.23 [ 0.53 ] 0.15.0 Relative Risk (Fixed) 95% CI 0. 3.78 p=0.0% Test for overall effect z=0.07 ] Total events: 10 (Regional). 7.53 I =0. 1 (General) Test for heterogeneity chi-square=0.

1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.0 Relative Risk (Fixed) 95% CI 0. 3.99 ] 1.12 [ 0.01 0.4 100.07.Comparison 04.0% Test for overall effect z=0.1 1 10 100 Favours regional Favours general Comparison 04.21 df=1 p=0.39.08 ] 1. Published by John Wiley & Sons.41 p=0.65 I =0.6 40.86 [ 0.23 ] Total events: 10 (Regional). 2.9 32. 10 (Control) Test for heterogeneity chi-square=0.05.05 p=1 0.30. 3 (General) Test for heterogeneity chi-square=0.50 [ 0.7 0. 16.12. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 22 Vomiting Study Regional n/N Bigler 1985 McLaren 1978 Total (95% CI) 1/20 1/26 46 General n/N 2/20 1/29 49 22 Vomiting Relative Risk (Fixed) 95% CI Weight (%) 67.0% Test for overall effect z=0.0 Relative Risk (Fixed) 95% CI 0.1 100.51 ] 1.66 I =0.94 ] Total events: 2 (Regional).95 ] 0.19 df=1 p=0.02 [ 0.25 [ 0. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 21 Urine retention Study Regional n/N Berggren 1987 Bigler 1985 Total (95% CI) 5/28 5/20 48 Control n/N 6/29 4/20 49 21 Urine retention Relative Risk (Fixed) 95% CI Weight (%) 59.70 [ 0. Ltd 43 . 5. 3.01 0.47. 2.

4 0.98 p=0.8 0.0 0.84 ] 0.48.43 ] 0.50 p=0.59 Total (95% CI) p=0. 4.1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. 4.5% Test for overall effect z=1. Published by John Wiley & Sons. 0.99 p=0.43 ] Total events: 0 (Regional).3 02 Other: venography diagnosis Brichant 1995 McKenzie 1984 Subtotal (95% CI) 14/46 8/20 66 13/42 16/20 62 22.1 03 Other: fibrinogen scan diagnosis Davis 1981 Subtotal (95% CI) 17/37 37 30/39 39 47.12 I =59.2 26.9 3.003 0. 0.10 df=3 p=0.22 [ 0. 1.52. 30 (General) Test for heterogeneity: not applicable Test for overall effect z=2.72 [ 0.11 ] Total events: 22 (Regional). Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 23 Deep vein thrombosis Study Regional n/N 01 Fatal (underlying reason for death only) McLaren 1978 Subtotal (95% CI) 0/26 26 2/29 29 General n/N 23 Deep vein thrombosis Relative Risk (Fixed) 95% CI Weight (%) Relative Risk (Fixed) 95% CI 3. 0.2 48.89 ] 0.60 [ 0.88 ] Total events: 17 (Regional).22 [ 0. 0.01.Comparison 04.40.2% Test for overall effect z=2.38 I =3.47. 1.86 ] Total events: 39 (Regional). 29 (General) Test for heterogeneity chi-square=2.60 [ 0. Ltd 44 .01.64 [ 0.98 [ 0. 61 (General) Test for heterogeneity chi-square=3.01 0.9 0.01 129 130 100.88 ] 0.28.47 df=1 p=0.8 47. 2 (General) Test for heterogeneity: not applicable Test for overall effect z=0.50 [ 0.40.

13.1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. 71. Ltd 45 .2 3.6% Test for overall effect z=0.74 [ 0.94 ] Total events: 8 (Regional).17 [ 0.26. Published by John Wiley & Sons.01.0 Relative Risk (Fixed) 95% CI 3.59 ] 0.90 [ 0.22 ] 0.01.41 I =2.Comparison 04.1 10. 8.7 3.8 17.11.00 ] 2. 3.01 0.00 [ 0. Review: Anaesthesia for hip fracture surgery in adults Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 24 Pulmonary embolism Study Regional n/N Adams 1990 Berggren 1987 Bigler 1985 Brichant 1995 Davis 1981 Davis 1987 McKenzie 1984 McLaren 1978 Racle 1986 Total (95% CI) 1/24 2/28 2/20 1/46 0/64 0/259 1/73 0/26 1/35 575 General n/N 0/32 0/29 0/20 0/42 4/68 1/279 3/75 2/29 0/35 609 24 Pulmonary embolism Relative Risk (Fixed) 95% CI Weight (%) 3.22 ] 0.7 100. 103. 2.6 21.18 ] 5.8 0.01.36 [ 0.77 ] 0.26 p=0.6 3.12 [ 0.22 [ 0.17.8 32.15 ] 0.26. 98.22 df=8 p=0. 65.43 ] 3.00 [ 0. 4.17 ] 5.96 [ 0. 10 (General) Test for heterogeneity chi-square=8.4 3.04.34 [ 0. 1.42. 93.

98. 8. 2. 93.77 ] 0.22 ] 0.64 ] Total events: 8 (Regional).3 9. Published by John Wiley & Sons.01 0.17 [ 0.03 p=1 0.01. 3.96 [ 0. 71.6 10.7 9.13.12 [ 0.6 10.Comparison 04.59 ] 0.36 [ 0. Ltd 46 .22 [ 0. 103.5 100. 2.26.01.4 18.22 ] 0.17 ] 5.00 [ 0.00 [ 0. Review: Anaesthesia for hip fracture surgery in adults 25 Pulmonary embolism (random effects model) Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 25 Pulmonary embolism (random effects model) Study Regional n/N Adams 1990 Berggren 1987 Bigler 1985 Brichant 1995 Davis 1981 Davis 1987 McKenzie 1984 McLaren 1978 Racle 1986 Total (95% CI) 1/24 2/28 2/20 1/46 0/64 0/259 1/73 0/26 1/35 575 General n/N 0/32 0/29 0/20 0/42 4/68 1/279 3/75 2/29 0/35 609 Relative Risk (Random) 95% CI Weight (%) 9.17.04.01.37.43 ] 3.98 [ 0.41 I =2.8 9.6 10.74 [ 0.26.34 [ 0.22 df=8 p=0. 4.0 Relative Risk (Random) 95% CI 3. 65.00 ] 2.5 11.15 ] 0.1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.6% Test for overall effect z=0.11. 10 (General) Test for heterogeneity chi-square=8.18 ] 5.

2.52 ] 2.04.57 p=0.01.22 ] 3.13.47 02 Non fatal Berggren 1987 Bigler 1985 Brichant 1995 Racle 1986 Subtotal (95% CI) 2/28 1/20 1/46 1/35 129 0/29 0/20 0/42 0/35 126 24.17.00 [ 0.29 df=5 p=0. 103.59 ] 3.1 0. Ltd 47 . 65.13.4 24.2 12.9 24. Review: Anaesthesia for hip fracture surgery in adults 26 Pulmonary embolism (fatal and non fatal) Comparison: 01 Regional (spinal or epidural) versus general anaesthesia Outcome: 26 Pulmonary embolism (fatal and non fatal) Study Regional n/N 01 Fatal (reason for death only) Adams 1990 Bigler 1985 Davis 1981 Davis 1987 McKenzie 1984 McLaren 1978 Subtotal (95% CI) 1/24 1/20 0/64 0/259 1/73 0/26 466 0/32 0/20 4/68 1/279 3/75 2/29 503 3.17 [ 0. 3.51 I =0.22 ] 0.15 ] 0. 0 (General) Test for heterogeneity chi-square=0.43 ] 0.52 ] 0. 8.01. 1.Comparison 04. 69.29 ] p=0.5 19.0 5. 69. 10 (General) Test for heterogeneity chi-square=4.48 [ 0.22 [ 0.28 ] General n/N Relative Risk (Fixed) 95% CI Weight (%) Relative Risk (Fixed) 95% CI Total events: 3 (Regional). 16.13.6 100. 93.0% Test for overall effect z=1.8 25.34 [ 0.46 [ 0.36 [ 0.11.17 ] 3. Published by John Wiley & Sons.00 [ 0.74.77 ] 0.8 100.6 4.96 [ 0.18. 4.01 0.26. 71.1 Total events: 5 (Regional).1 36.0% Test for overall effect z=1.01.0 24.12 [ 0.99 I =0.1 1 10 100 Favours regional Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.00 [ 0.0 3.11 df=3 p=0.74 [ 0.18 ] 3.

01 0.0 100.00 [ -14. Review: Anaesthesia for hip fracture surgery in adults 02 Length of operation Comparison: 02 Spinal and ’light’ general anaesthetic versus general anaesthetic Outcome: 02 Length of operation Study N White 1980 Total (95% CI) 20 20 p=1 Spinal (+) Mean(SD) 58. 14.1 1 10 100 Favours spinal (+) Favours general Comparison 04.00 [ -14. 5 (General) Test for heterogeneity: not applicable Test for overall effect z=0.0 -50.0 Favours spinal (+) Favours general Comparison 04.89.0 100.25. Review: Anaesthesia for hip fracture surgery in adults 01 Mortality .00) Weighted Mean Difference (Fixed) 95% CI Weight (%) 100.00) N 20 20 General Mean(SD) 58.1 month Comparison: 02 Spinal and ’light’ general anaesthetic versus general anaesthetic Outcome: 01 Mortality .0 Relative Risk (Fixed) 95% CI 0.38 p=0.0 0 50.55 ] Total events: 4 (Spinal (+)). Review: Anaesthesia for hip fracture surgery in adults Comparison: 02 Spinal and ’light’ general anaesthetic versus general anaesthetic Outcome: 03 Pneumonia Study Spinal (+) n/N White 1980 Total (95% CI) 4/20 20 General n/N 5/20 20 03 Pneumonia Relative Risk (Fixed) 95% CI Weight (%) 100. 2.0 100.80 [ 0.1 1 10 100 Favours spinal (+) Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.89.0 0.0 Relative Risk (Fixed) 95% CI Not estimable Not estimable Total events: 0 (Spinal (+)).80 [ 0.55 ] 0.89 ] Test for heterogeneity: not applicable Test for overall effect z=0.89 ] 0. Ltd 48 . 0 (General) Test for heterogeneity: not applicable Test for overall effect: not applicable 0.00 (25. 2. Published by John Wiley & Sons.0 Weighted Mean Difference (Fixed) 95% CI 0.1 month Study Spinal (+) n/N x White 1980 Total (95% CI) 0/20 20 General n/N 0/20 20 Relative Risk (Fixed) 95% CI Weight (%) 0.00 -100.00 (23. 14.Comparison 04.01 0.25.7 0.

23. 7.0 Relative Risk (Fixed) 95% CI 0.23.69 p=0.0 100. Review: Anaesthesia for hip fracture surgery in adults 04 Confusional state Comparison: 02 Spinal and ’light’ general anaesthetic versus general anaesthetic Outcome: 04 Confusional state Study Spinal (+) n/N White 1980 Total (95% CI) 3/20 20 General n/N 3/20 20 Relative Risk (Fixed) 95% CI Weight (%) 100.72 ] 0. Ltd 49 . Published by John Wiley & Sons.0 100.1 1 10 100 Favours spinal (+) Favours general Comparison 04. 3 (General) Test for heterogeneity: not applicable Test for overall effect z=0.0 Relative Risk (Fixed) 95% CI 1.Comparison 04.37 ] 1.01 0. Review: Anaesthesia for hip fracture surgery in adults 05 Deep vein thrombosis Comparison: 02 Spinal and ’light’ general anaesthetic versus general anaesthetic Outcome: 05 Deep vein thrombosis Study Spinal (+) n/N White 1980 Total (95% CI) 0/20 20 General n/N 1/20 20 Relative Risk (Fixed) 95% CI Weight (%) 100.01 0.00 p=1 0.72 ] Total events: 0 (Spinal (+)).33 [ 0.33 [ 0. 7.01.5 0.01. 1 (General) Test for heterogeneity: not applicable Test for overall effect z=0.00 [ 0.37 ] Total events: 3 (Spinal (+)). 4.00 [ 0. 4.1 1 10 100 Favours spinal (+) Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.

61 ] Total events: 0 (Regional).0003 0.001 0.61 ] 0. 24 (Nerve blocks) Test for heterogeneity chi-square=0.01. 5 (Nerve blocks) Test for heterogeneity: not applicable Test for overall effect z=1.0% Test for overall effect z=3.63 Total (95% CI) p=0.0 100.12.001 0. 17.21 p=0.9 21.02.83 ] Nerve block n/N Relative Risk (Fixed) 95% CI Weight (%) Relative Risk (Fixed) 95% CI Total events: 18 (Regional (spinal)). Ltd 50 .12.1 39 40 100.02.1 0.Comparison 04.0 6.83 ] 6. 0.001 02 Regional (spinal) block versus lumbar plexus.1 Favours regional 1 10 100 1000 Favours nerve blocks Comparison 04. Published by John Wiley & Sons.00 [ 2.48 df=1 p=0.23 [ 0.0 0. Review: Anaesthesia for hip fracture surgery in adults 02 Operative hypotension Comparison: 03 Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome: 02 Operative hypotension Study Regional (spinal) n/N 01 Regional (spinal) block versus lumbar plexus block Eyrolle 1998 Total (95% CI) 18/25 25 3/25 25 100.10 [ 0. sacral and iliac crest block de Visme 2000 Subtotal (95% CI) 0/14 14 5/15 15 21.10.49 I =0.59 ] Nerve blocks n/N Relative Risk (Fixed) 95% CI Weight (%) Relative Risk (Fixed) 95% CI Total events: 5 (Regional).66 p=0.1 1 10 100 Favours regional Favours nerve block Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.22 p=0.01 0.1 78. 3 (Nerve block) Test for heterogeneity: not applicable Test for overall effect z=3.00 [ 2.26 [ 0. 1. 17.59 ] 0.01. 0.9 0. Review: Anaesthesia for hip fracture surgery in adults 01 Incomplete or unsatisfactory analgesia Comparison: 03 Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome: 01 Incomplete or unsatisfactory analgesia Study Regional n/N 01 Regional (spinal) block versus lumbar plexus block Eyrolle 1998 Subtotal (95% CI) 5/25 25 19/25 25 78.50 ] Total events: 5 (Regional). 0. 1.01 0. 19 (Nerve blocks) Test for heterogeneity: not applicable Test for overall effect z=3.10 [ 0.26 [ 0.

0 5. 30.69 ] 16.00 (2.00 [ 2. Review: Anaesthesia for hip fracture surgery in adults 04 Mean dose of ephedrine used (mg) Comparison: 03 Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome: 04 Mean dose of ephedrine used (mg) Study N Regional Mean(SD) N Nerve block Mean(SD) Weighted Mean Difference (Fixed) 95% CI Weight (%) Weighted Mean Difference (Fixed) 95% CI 01 Regional (spinal) block versus lumbar plexus block Eyrolle 1998 Subtotal (95% CI) 25 25 p<0.00) 15 15 30.0 -50.00 (5. 17.00) 15 15 3. sacral and iliac crest block de Visme 2000 Subtotal (95% CI) 14 14 p=0.7 10.32 ] 5.13 -100.Comparison 04. 17.00) 3.3 5. Review: Anaesthesia for hip fracture surgery in adults 03 Mean fall in arterial blood pressure (mmHg) Comparison: 03 Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome: 03 Mean fall in arterial blood pressure (mmHg) Study N Regional Mean(SD) N Nerve block Mean(SD) Weighted Mean Difference (Fixed) 95% CI Weight (%) Weighted Mean Difference (Fixed) 95% CI 02 Regional (spinal) block versus lumbar plexus.00) 100.80 [ 4.00 (14.08 df=1 p=0.28.00 (18.0 -50.46 02 Regional (spinal) block versus lumbar plexus.0 Favours regional Favours nerve block Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration. 7.20 (2.00001 7.03 46.70) 96.80) 25 25 1.24.46. Ltd 51 .01 40 p<0.80 [ 4. 7.0 100.76 ] Test for heterogeneity: not applicable Test for overall effect z=2.32 ] Test for heterogeneity: not applicable Test for overall effect z=7.76 ] 10.0 16.31.0 100. 7.00 [ 1.28.8% Test for overall effect z=7.0 Favours regional Favours nerve block Comparison 04. sacral and iliac crest block de Visme 2000 Total (95% CI) 14 14 p=0.45 ] 13.0 0 50.00001 100.7 3.53 Total (95% CI) 39 Test for heterogeneity chi-square=1.80 -100. Published by John Wiley & Sons.3 96.0 0 50.00 [ 2.96 [ 4.0 100. 30.24.31.00 [ 1.69 ] Test for heterogeneity: not applicable Test for overall effect z=2.30 I =7.00 (22.

Published by John Wiley & Sons.29 ] 6.78. 46.78.0 6. sacral and iliac crest block de Visme 2000 Total (95% CI) 5/14 14 6/15 15 100.0 6.28 ] Total events: 5 (Regional).72 p=0.72 p=0.00 [ 0. Review: Anaesthesia for hip fracture surgery in adults 06 Post-operative confusion Comparison: 03 Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome: 06 Post-operative confusion Study Regional n/N Nerve block n/N Relative Risk (Fixed) 95% CI Weight (%) Relative Risk (Fixed) 95% CI 02 Regional (spinal) block versus lumbar plexus.0 100.29 ] Total events: 6 (Regional (spinal)).Comparison 04.78. sacral and iliac crest block x de Visme 2000 Subtotal (95% CI) 0/14 14 0/15 15 0.00 [ 0. Ltd 52 . 1 (Nerve block) Test for heterogeneity: not applicable Test for overall effect z=1.35.0 100. 6 (Nerve block) Test for heterogeneity: not applicable Test for overall effect z=0.89 [ 0.09 0.01 0. 46.89 [ 0.1 1 10 100 Favours regional Favours nerve block Comparison 04.09 02 Regional (spinal) block versus lumbar plexus.1 1 10 100 Favours regional Favours nerve blocks Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.0 0.0 0. 46. 1 (Nerve block) Test for heterogeneity: not applicable Test for overall effect z=1.29 ] Total events: 6 (Regional (spinal)).35.01 0.00 [ 0. 2.28 ] 0. 0 (Nerve block) Test for heterogeneity: not applicable Test for overall effect: not applicable Total (95% CI) 39 40 100. Review: Anaesthesia for hip fracture surgery in adults Comparison: 03 Regional (spinal or epidural) versus lumbar plexus nerve blocks Outcome: 05 Adverse effects Study Regional (spinal) n/N 01 Regional (spinal) block versus lumbar plexus block Eyrolle 1998 Subtotal (95% CI) 6/25 25 1/25 25 Nerve block n/N 05 Adverse effects Relative Risk (Fixed) 95% CI Weight (%) Relative Risk (Fixed) 95% CI 100. 2.24 p=0.0 Not estimable Not estimable Total events: 0 (Regional (spinal)).8 0.

9 (General) Test for heterogeneity: not applicable Test for overall effect z=0.17 ] 1.87 ] 0.0 Relative Risk (Fixed) 95% CI 1.46.00 p=1 0. Review: Anaesthesia for hip fracture surgery in adults Comparison: 04 Intravenous ketamine versus general anaesthesia Outcome: 02 Myocardial infarction Study Ketamine n/N Spreadbury 1980 Total (95% CI) 0/30 30 General n/N 1/30 30 02 Myocardial infarction Relative Risk (Fixed) 95% CI Weight (%) 100.0 Relative Risk (Fixed) 95% CI 0.0 100.01 0.Comparison 04.during hospital stay Relative Risk (Fixed) 95% CI Weight (%) 100. 2.01 0.5 0.33 [ 0.01.during hospital stay Study Ketamine n/N Spreadbury 1980 Total (95% CI) 9/30 30 General n/N 9/30 30 01 Mortality .68 p=0.00 [ 0. Ltd 53 . Review: Anaesthesia for hip fracture surgery in adults Comparison: 04 Intravenous ketamine versus general anaesthesia Outcome: 01 Mortality .00 [ 0. Published by John Wiley & Sons.46. 2.87 ] Total events: 0 (Ketamine). 7. 1 (General) Test for heterogeneity: not applicable Test for overall effect z=0.17 ] Total events: 9 (Ketamine).01.1 1 10 100 Favours ketamine Favours general Comparison 04.1 1 10 100 Favours ketamine Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.0 100. 7.33 [ 0.

0 100. 2.20 [ 0.43 ] Test for heterogeneity: not applicable Test for overall effect z=3.65 ] 0.00 (8.0 0 50.01.00 ] Total events: 0 (Ketamine).1 1 10 100 Favours ketamine Favours general Comparison 04.00 [ 5.20 [ 0.01.31 p=0.1 1 10 100 Favours ketamine Favours general Comparison 04.Comparison 04.66 -100. 4. 4. Ltd 54 .65 ] Total events: 0 (Ketamine).01. 18.3 0.0 -50. Published by John Wiley & Sons. Review: Anaesthesia for hip fracture surgery in adults 05 Length of hospital stay (discharge home) Comparison: 04 Intravenous ketamine versus general anaesthesia Outcome: 05 Length of hospital stay (discharge home) Study N Spreadbury 1980 Total (95% CI) 19 19 p=0.00 (12.00 ] 0.0003 Ketamine Mean(SD) 36.01 0. 2 (General) Test for heterogeneity: not applicable Test for overall effect z=1.00) Weighted Mean Difference (Fixed) 95% CI Weight (%) 100.0 Favours ketamine Favours general Anaesthesia for hip fracture surgery in adults (Review) Copyright © 2004 The Cochrane Collaboration.00 [ 5.01.2 0. Review: Anaesthesia for hip fracture surgery in adults Comparison: 04 Intravenous ketamine versus general anaesthesia Outcome: 04 Pulmonary embolism Study Ketamine n/N Spreadbury 1980 Total (95% CI) 0/30 30 General n/N 3/30 30 04 Pulmonary embolism Relative Risk (Fixed) 95% CI Weight (%) 100. 18.0 100.57.0 Weighted Mean Difference (Fixed) 95% CI 12.14 [ 0. 2.0 100.01 0.05 p=0.57.0 100.0 Relative Risk (Fixed) 95% CI 0. 3 (General) Test for heterogeneity: not applicable Test for overall effect z=1.14 [ 0.00) N 20 20 General Mean(SD) 24.43 ] 12.0 Relative Risk (Fixed) 95% CI 0. Review: Anaesthesia for hip fracture surgery in adults Comparison: 04 Intravenous ketamine versus general anaesthesia Outcome: 03 Congestive cardiac failure Study Ketamine n/N Spreadbury 1980 Total (95% CI) 0/30 30 General n/N 2/30 30 03 Congestive cardiac failure Relative Risk (Fixed) 95% CI Weight (%) 100.

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