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Is Regional Anesthesia Better than General Anesthesia?

(Originally posted 21 September 2000 on About Anesthesiology)

INTRODUCTION
The debate about whether regional anesthesia is better than general anesthesia in terms of morbidity and mortality continues to be a topic of great interest and fervent debate. For most people looking at this question, it seems somewhat "logical" or "a gut feeling" that regional anesthesia would be safer and better for the patient - but the scientific data has is not really present to support this conclusion. There have been some specific incidents where regional anesthesia has been shown to be of benefit - but the statement that regional is somehow better or safer than general anesthesia still cannot be made definitively.

WHY IS THE DATA NOT THERE?
Part of the problem with addressing this question is that differences in morbidity and mortality between any two techniques are likely very small. This is a testament to the fact that anesthesia is much safer than it ever has been before and that new developments in technology, pharmaceuticals, etc. continue to increase this safety profile. With a small number of events to identify and compare, it takes a tremendously large trial size to show statistically significant differences. As a result, very large studies involving many thousands of patients are required.

RECENT META-ANALYSIS DATA PRESENTED
At the recent American Society of Regional Anesthesia meeting in Orlando, Florida, Dr. Stephen Schug presented results of a meta-analysis that adds some fuel to the debate. The work, done at the University of Auckland in New Zealand, has been submitted for publication and involves analysis of data from over nine thousand patients. In the absence of a study designed to involve this high number of patients, a meta-analysis of this sort is the only way to generate the necessary numbers to show statistically significant results.

The results of the meta-analysis provide evidence that regional anesthesia is better than general anesthesia when looking at mortality and serious (but not fatal) morbidity. The specific focus was neuraxial blockade (spinal and epidural anesthesia) compared to general anesthesia. One hundred and forty two separate trials were included with a total of 9,553 patients.

Overall mortality in the month after surgery was decreased about 30% in patients that received regional anesthesia (epidural or spinal) - this works out to be approximately one less death per one hundred patients. In addition, regional anesthesia reduced the incidence of deep vein thrombosis (blood clots) by over 40%, the incidence of pulmonary embolism by over 50% and need for transfusion by 50%.

In addition, myocardial infarction was reduced by one third, pneumonia was reduced almost 40% and respiratory depression reduced almost 60%. Renal failure was also decreased postoperatively in the regional anesthesia group.

WHAT REMAINS TO BE DONE
A well performed meta-analysis can definitely provide insight and useful conclusions. However, as most critics will note, it does not take the place of a well controlled, randomized trial. This definitive randomized trial, which must be quite large out of statistical necessity, remains to be done. In addition, I believe it will be of interest to see how the use of regional anesthesia versus general anesthesia affects the cost of care, the cost of treating complications, etc. This work does give us a great deal of "food for thought" as well as some more "ammunition for debate" to those who believe that regional anesthesia is indeed better than general anesthesia. It will be interesting to see what develops in this area of study in the future.

 

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