Association between neuraxial anaesthesia or general anaesthesia for lower limb revascularisation surgery in adults and clinical outcomes: population based comparative effectiveness study

Derek J Roberts, Sudhir K Nagpal, Dalibor Kubelik, Timothy Brandys, Henry T Stelfox, Manoj M Lalu, Alan J Forster, Colin Jl McCartney, Daniel I McIsaac, Derek J Roberts, Sudhir K Nagpal, Dalibor Kubelik, Timothy Brandys, Henry T Stelfox, Manoj M Lalu, Alan J Forster, Colin Jl McCartney, Daniel I McIsaac

Abstract

Objective: To examine the associations between neuraxial anaesthesia or general anaesthesia and clinical outcomes, length of hospital stay, and readmission in adults undergoing lower limb revascularisation surgery.

Design: Comparative effectiveness study using linked, validated, population based databases.

Setting: Ontario, Canada, 1 April 2002 to 31 March 2015.

Participants: 20 988 patients Ontario residents aged 18 years or older who underwent their first lower limb revascularisation surgery in hospitals performing 50 or more of these surgeries annually.

Main outcome measures: Primary outcome was 30 day all cause mortality. Secondary outcomes were in-hospital cardiopulmonary and renal complications, length of hospital stay, and 30 day readmissions. Multivariable, mixed effects regression models, adjusting for patient, procedural, and hospital characteristics, were used to estimate associations between anaesthetic technique and outcomes. Robustness of analyses were evaluated by conducting instrumental variable, propensity score matched, and survival sensitivity analyses.

Results: Of 20 988 patients who underwent lower limb revascularisation surgery, 6453 (30.7%) received neuraxial anaesthesia and 14 535 (69.3%) received general anaesthesia. The percentage of neuraxial anaesthesia use ranged from 0.6% to 90.6% across included hospitals. Furthermore, use of neuraxial anaesthesia declined by 17% over the study period. Death within 30 days occurred in 204 (3.2%) patients who received neuraxial anaesthesia and 646 (4.4%) patients who received general anaesthesia. After multivariable, multilevel adjustment, use of neuraxial anaesthesia compared with use of general anaesthesia was associated with decreased 30 day mortality (absolute risk reduction 0.72%, 95% confidence interval 0.65% to 0.79%; odds ratio 0.68, 95% confidence interval 0.57 to 0.83; number needed to treat to prevent one death=139). A similar direction and magnitude of association was found in instrumental variable, propensity score matched, and survival analyses. Use of neuraxial anaesthesia compared with use of general anaesthesia was also associated with decreased in-hospital cardiopulmonary and renal complications (odds ratio 0.73, 0.63 to 0.85) and a reduced length of hospital stay (-0.5 days, -0.3 to-0.6 days).

Conclusions: Use of neuraxial anaesthesia compared with general anaesthesia for lower limb revascularisation surgery was associated with decreased 30 day mortality and hospital length of stay. These findings might have been related to reduced cardiopulmonary and renal complications after neuraxial anaesthesia and support the increased use of neuraxial anaesthesia in patients undergoing these surgeries until the results of a large, confirmatory randomised trial become available.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Fig 1
Fig 1
Flow of patients through the study
Fig 2
Fig 2
Loess smoothed plot of percentage of neuraxial anaesthesia use across the study period. Shaded areas around the plotted line represent 95% confidence intervals

References

    1. Adam DJ, Beard JD, Cleveland T, et al. BASIL trial participants Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet 2005;366:1925-34. 10.1016/S0140-6736(05)67704-5
    1. Bradbury AW, Adam DJ, Bell J, et al. BASIL trial Participants Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: An intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg 2010;51(Suppl):5S-17S. 10.1016/j.jvs.2010.01.073
    1. Menard MT, Farber A, Assmann SF, et al. Design and Rationale of the Best Endovascular Versus Best Surgical Therapy for Patients With Critical Limb Ischemia (BEST-CLI) Trial. J Am Heart Assoc 2016;5:e003219. 10.1161/JAHA.116.003219
    1. Popplewell MA, Davies H, Jarrett H, et al. BASIL-2 Trial Investigators Bypass versus angio plasty in severe ischaemia of the leg - 2 (BASIL-2) trial: study protocol for a randomised controlled trial. Trials 2016;17:11. 10.1186/s13063-015-1114-2
    1. Mustapha JA, Katzen BT, Neville RF, et al. Determinants of Long-Term Outcomes and Costs in the Management of Critical Limb Ischemia: A Population-Based Cohort Study. J Am Heart Assoc 2018;7:e009724. 10.1161/JAHA.118.009724
    1. Nejim BJ, Wang S, Arhuidese I, et al. Regional variation in the cost of infrainguinal lower extremity bypass surgery in the United States. J Vasc Surg 2018;67:1170-1180.e4. 10.1016/j.jvs.2017.08.055
    1. Goodney PP, Travis LL, Brooke BS, et al. Relationship between regional spending on vascular care and amputation rate. JAMA Surg 2014;149:34-42. 10.1001/jamasurg.2013.4277
    1. Antoniou GA, Georgiadis GS, Antoniou SA, Makar RR, Smout JD, Torella F. Bypass surgery for chronic lower limb ischaemia. Cochrane Database Syst Rev 2017;4:CD002000. 10.1002/14651858.CD002000.pub3
    1. LaMuraglia GM, Conrad MF, Chung T, Hutter M, Watkins MT, Cambria RP. Significant perioperative morbidity accompanies contemporary infrainguinal bypass surgery: an NSQIP report. J Vasc Surg 2009;50:299-304, 304.e1-4. 10.1016/j.jvs.2009.01.043
    1. Fowkes FG, Aboyans V, Fowkes FJ, McDermott MM, Sampson UK, Criqui MH. Peripheral artery disease: epidemiology and global perspectives. Nat Rev Cardiol 2017;14:156-70. 10.1038/nrcardio.2016.179
    1. Veronese N, Cereda E, Stubbs B, et al. Risk of cardiovascular disease morbidity and mortality in frail and pre-frail older adults: Results from a meta-analysis and exploratory meta-regression analysis. Ageing Res Rev 2017;35:63-73. 10.1016/j.arr.2017.01.003
    1. Siracuse JJ, Menard MT, Eslami MH, et al. Vascular Quality Initiative Comparison of open and endovascular treatment of patients with critical limb ischemia in the Vascular Quality Initiative. J Vasc Surg 2016;63:958-65.e1. 10.1016/j.jvs.2015.09.063
    1. Rosenfeld BA, Beattie C, Christopherson R, et al. Perioperative Ischemia Randomized Anesthesia Trial Study Group The effects of different anesthetic regimens on fibrinolysis and the development of postoperative arterial thrombosis. Anesthesiology 1993;79:435-43. 10.1097/00000542-199309000-00005
    1. Tuman KJ, McCarthy RJ, March RJ, DeLaria GA, Patel RV, Ivankovich AD. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg 1991;73:696-704. 10.1213/00000539-199112000-00005
    1. Breslow MJ, Parker SD, Frank SM, et al. The PIRAT Study Group Determinants of catecholamine and cortisol responses to lower extremity revascularization. Anesthesiology 1993;79:1202-9. 10.1097/00000542-199312000-00010
    1. Parker SD, Breslow MJ, Frank SM, et al. Perioperative Ischemia Randomized Anesthesia Trial Study Group Catecholamine and cortisol responses to lower extremity revascularization: correlation with outcome variables. Crit Care Med 1995;23:1954-61. 10.1097/00003246-199512000-00003
    1. Christopherson R, Glavan NJ, Norris EJ, et al. Perioperative Ischemia Randomized Anesthesia Trial (PIRAT) Study Group Control of blood pressure and heart rate in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. J Clin Anesth 1996;8:578-84. 10.1016/S0952-8180(96)00139-0
    1. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000;321:1493. 10.1136/bmj.321.7275.1493
    1. Guay J, Choi P, Suresh S, Albert N, Kopp S, Pace NL. Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2014;(1):CD010108. 10.1002/14651858.CD010108.pub2
    1. Barbosa FT, Jucá MJ, Castro AA, Cavalcante JC. Neuraxial anaesthesia for lower-limb revascularization. Cochrane Database Syst Rev 2013;(7):CD007083.
    1. Ghanami RJ, Hurie J, Andrews JS, et al. Anesthesia-based evaluation of outcomes of lower-extremity vascular bypass procedures. Ann Vasc Surg 2013;27:199-207. 10.1016/j.avsg.2012.04.006
    1. Singh N, Sidawy AN, Dezee K, et al. The effects of the type of anesthesia on outcomes of lower extremity infrainguinal bypass. J Vasc Surg 2006;44:964-8, discussion 968-70. 10.1016/j.jvs.2006.06.035
    1. Sgroi MD, McFarland G, Mell MW. Utilization of regional versus general anesthesia and its impact on lower extremity bypass outcomes. J Vasc Surg 2019;69:1874-9. 10.1016/j.jvs.2018.08.190
    1. Sox HC, Goodman SN. The methods of comparative effectiveness research. Annu Rev Public Health 2012;33:425-45. 10.1146/annurev-publhealth-031811-124610
    1. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, STROBE Initiative Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007;335:806-8. 10.1136/
    1. Benchimol EI, Smeeth L, Guttmann A, et al. RECORD Working Committee The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med 2015;12:e1001885. 10.1371/journal.pmed.1001885
    1. Vision and mandate. .
    1. ICES About ICES. .
    1. Wijeysundera DN, Beattie WS, Austin PC, Hux JE, Laupacis A. Epidural anaesthesia and survival after intermediate-to-high risk non-cardiac surgery: a population-based cohort study. Lancet 2008;372:562-9. 10.1016/S0140-6736(08)61121-6
    1. Wijeysundera DN, Austin PC, Beattie WS, Hux JE, Laupacis A. A population-based study of anesthesia consultation before major noncardiac surgery. Arch Intern Med 2009;169:595-602. 10.1001/archinternmed.2009.3
    1. Wijeysundera DN, Beattie WS, Karkouti K, Neuman MD, Austin PC, Laupacis A. Association of echocardiography before major elective non-cardiac surgery with postoperative survival and length of hospital stay: population based cohort study. BMJ 2011;342:d3695. 10.1136/bmj.d3695
    1. Richards J, Brown A, Homan C. The data quality study of the Canadian Discharge Abstract Database. Proc Stat Canada Symp 2001.
    1. Miller’s Anesthesia. 9th ed Elsevier, 2019.
    1. McIsaac DI, Wijeysundera DN, Bryson GL, Huang A, McCartney CJL, van Walraven C. Hospital-, anesthesiologist-, and patient-level variation in primary anesthesia type for hip fracture surgery: a population-based cross-sectional analysis. Anesthesiology 2018;129:1121-31. 10.1097/ALN.0000000000002453
    1. Bennett KM, Kent KC, Schumacher J, Greenberg CC, Scarborough JE. Targeting the most important complications in vascular surgery. J Vasc Surg 2017;65:793-803. 10.1016/j.jvs.2016.08.107
    1. Tu K, Mitiku T, Guo H, Lee DS, Tu JV. Myocardial infarction and the validation of physician billing and hospitalization data using electronic medical records. Chronic Dis Can 2010;30:141-6. 10.24095/hpcdp.30.4.06
    1. Tu K, Campbell NR, Chen ZL, Cauch-Dudek KJ, McAlister FA. Accuracy of administrative databases in identifying patients with hypertension. Open Med 2007;1:e18-26.
    1. Schultz SE, Rothwell DM, Chen Z, Tu K. Identifying cases of congestive heart failure from administrative data: a validation study using primary care patient records. Chronic Dis Inj Can 2013;33:160-6. 10.24095/hpcdp.33.3.06
    1. Hux JE, Ivis F, Flintoft V, Bica A. Diabetes in Ontario: determination of prevalence and incidence using a validated administrative data algorithm. Diabetes Care 2002;25:512-6. 10.2337/diacare.25.3.512
    1. Gershon AS, Wang C, Guan J, Vasilevska-Ristovska J, Cicutto L, To T. Identifying individuals with physcian diagnosed COPD in health administrative databases. COPD 2009;6:388-94. 10.1080/15412550903140865
    1. van Walraven C, McAlister FA, Bakal JA, Hawken S, Donzé J. External validation of the Hospital-patient One-year Mortality Risk (HOMR) model for predicting death within 1 year after hospital admission. CMAJ 2015;187:725-33. 10.1503/cmaj.150209
    1. Chen G, Lix L, Tu K, et al. Hypertension Outcome and Surveillance Team Influence of Using Different Databases and ‘Look Back’ Intervals to Define Comorbidity Profiles for Patients with Newly Diagnosed Hypertension: Implications for Health Services Researchers. PLoS One 2016;11:e0162074. 10.1371/journal.pone.0162074
    1. Sternberg SA, Bentur N, Abrams C, et al. Identifying frail older people using predictive modeling. Am J Manag Care 2012;18:e392-7.
    1. McIsaac DI, Bryson GL, van Walraven C. Association of Frailty and 1-Year Postoperative Mortality Following Major Elective Noncardiac Surgery: A Population-Based Cohort Study. JAMA Surg 2016;151:538-45. 10.1001/jamasurg.2015.5085
    1. The Johns Hopkins ACG System. Excerpt from Version 11.0 Technical Reference Guide. .
    1. McIsaac DI, Wong CA, Bryson GL, van Walraven C. Association of polypharmacy with survival, complications, and healthcare resource use after elective noncardiac surgery: a population-based cohort study. Anesthesiology 2018;128:1140-50. 10.1097/ALN.0000000000002124
    1. Vittinghoff E, McCulloch CE. Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol 2007;165:710-8. 10.1093/aje/kwk052
    1. Austin PC. Using the standardized difference to compare the prevalence of a binary variable between two groups in observational research. Commun Stat Simul Comput 2009;38:1228-34 10.1080/03610910902859574 .
    1. Austin PC, Ghali WA, Tu JV. A comparison of several regression models for analysing cost of CABG surgery. Stat Med 2003;22:2799-815. 10.1002/sim.1442
    1. Austin PC, Laupacis A. A tutorial on methods to estimating clinically and policy-meaningful measures of treatment effects in prospective observational studies: a review. Int J Biostat 2011;7:6. 10.2202/1557-4679.1285
    1. The ACG® system. .
    1. Terza JV, Basu A, Rathouz PJ. Two-stage residual inclusion estimation: addressing endogeneity in health econometric modeling. J Health Econ 2008;27:531-43. 10.1016/j.jhealeco.2007.09.009
    1. Terza JV. Two-stage residual inclusion estimation in health services research and health economics. Health Serv Res 2018;53:1890-9. 10.1111/1475-6773.12714
    1. Koladjo BF, Escolano S, Tubert-Bitter P. Instrumental variable analysis in the context of dichotomous outcome and exposure with a numerical experiment in pharmacoepidemiology. BMC Med Res Methodol 2018;18:61. 10.1186/s12874-018-0513-y
    1. Lousdal ML. An introduction to instrumental variable assumptions, validation and estimation. Emerg Themes Epidemiol 2018;15:1. 10.1186/s12982-018-0069-7
    1. Brookhart MA, Schneeweiss S. Preference-based instrumental variable methods for the estimation of treatment effects: assessing validity and interpreting results. Int J Biostat 2007;3:14. 10.2202/1557-4679.1072
    1. Angrist JD, Imbens GW, Rubin DB. Identification of causal effects using instrumental variables. J Am Stat Assoc 1996;91:444-55 10.1080/01621459.1996.10476902.
    1. Austin PC, Stuart EA. Estimating the effect of treatment on binary outcomes using full matching on the propensity score. Stat Methods Med Res 2017;26:2505-25. 10.1177/0962280215601134
    1. VanderWeele TJ, Ding P. Sensitivity analysis in observational research: introducing the E-value. Ann Intern Med 2017;167:268-74. 10.7326/M16-2607
    1. Barshes NR, Menard MT, Nguyen LL, Bafford R, Ozaki CK, Belkin M. Infrainguinal bypass is associated with lower perioperative mortality than major amputation in high-risk surgical candidates. J Vasc Surg 2011;53:1251-1259.e1. 10.1016/j.jvs.2010.11.099
    1. Tsay C, Luo J, Zhang Y, Attaran R, Dardik A, Ochoa Chaar CI. Perioperative outcomes of lower extremity revascularization for rest pain and tissue loss. Ann Vasc Surg 2020;66:493-501. 10.1016/j.avsg.2019.11.019
    1. Romano PS, Mull HJ, Rivard PE, et al. Validity of selected AHRQ patient safety indicators based on VA National Surgical Quality Improvement Program data. Health Serv Res 2009;44:182-204. 10.1111/j.1475-6773.2008.00905.x
    1. Dovell G, Rogers CA, Armstrong R, Harris RA, Hinchliffe RJ, Mouton R. The effect of mode of anaesthesia on outcomes after elective endovascular repair of abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2020;59:729-38. 10.1016/j.ejvs.2020.01.031
    1. Cozowicz C, Poeran J, Memtsoudis SG. Epidemiology, trends, and disparities in regional anaesthesia for orthopaedic surgery. Br J Anaesth 2015;115(Suppl 2):ii57-67. 10.1093/bja/aev381
    1. Cozowicz C, Poeran J, Zubizarreta N, Mazumdar M, Memtsoudis SG. Trends in the use of regional anesthesia: neuraxial and peripheral nerve blocks. Reg Anesth Pain Med 2016;41:43-9. 10.1097/AAP.0000000000000342
    1. Memtsoudis SG, Fiasconaro M, Soffin EM, et al. Enhanced recovery after surgery components and perioperative outcomes: a nationwide observational study. Br J Anaesth 2020;124:638-47. 10.1016/j.bja.2020.01.017
    1. McIsaac DI, Wijeysundera DN, Huang A, Bryson GL, van Walraven C. Association of hospital-level neuraxial anesthesia use for hip fracture surgery with outcomes: a population-based cohort study. Anesthesiology 2018;128:480-91. 10.1097/ALN.0000000000001899
    1. Yılmaz İnal F, Yılmaz Y, Daşkaya H, et al. Evaluation of the attitudes of surgeons about regional anesthesia: a survey study. Local Reg Anesth 2019;12:89-95. 10.2147/LRA.S211469
    1. Fleischut PM, Eskreis-Winkler JM, Gaber-Baylis LK, et al. Variability in anesthetic care for total knee arthroplasty: an analysis from the anesthesia quality institute. Am J Med Qual 2015;30:172-9. 10.1177/1062860614525989
    1. Matthey PW, Finegan BA, Finucane BT. The public’s fears about and perceptions of regional anesthesia. Reg Anesth Pain Med 2004;29:96-101. 10.1016/j.rapm.2003.10.017
    1. Oldman M, McCartney CJ, Leung A, et al. A survey of orthopedic surgeons’ attitudes and knowledge regarding regional anesthesia [table of contents.]. Anesth Analg 2004;98:1486-90. 10.1213/01.ANE.0000113549.98873.B1
    1. Pelinka LE, Pelinka H, Leixnering M, Mauritz W. Why patients choose regional anesthesia for orthopedic and trauma surgery. Arch Orthop Trauma Surg 2003;123:164-7. 10.1007/s00402-003-0479-y
    1. Shevde K, Panagopoulos G. A survey of 800 patients’ knowledge, attitudes, and concerns regarding anesthesia. Anesth Analg 1991;73:190-8. 10.1213/00000539-199108000-00013
    1. Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 2013;258:1-7. 10.1097/SLA.0b013e318296c732
    1. Shulman MA, Myles PS, Chan MT, McIlroy DR, Wallace S, Ponsford J. Measurement of disability-free survival after surgery. Anesthesiology 2015;122:524-36. 10.1097/ALN.0000000000000586
    1. Cook TM, Counsell D, Wildsmith JA, Royal College of Anaesthetists Third National Audit Project Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009;102:179-90. 10.1093/bja/aen360

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner