Preoperative Epidural Analgesia Decreases Cardiac Events, Mortality Risk Among Patients With Hip Fracture

According to results of a systematic review, perioperative cardiac events and mortality were reduced among patients with hip fracture who received preoperative epidural analgesia. These findings were published in Pain Medicine.

Researchers from the University of British Columbia searched publication databases through June 2019 for studies of anesthesia and analgesia strategies used for patients with hip fractures. Clinical outcomes were assessed for 4 randomized controlled trials comprising 221 patients.

A total of 107 patients received epidural analgesia, 104 had intramuscular or intravenous opioids, and 10 had ultrasound-guided continuous 3-in-1 blocks. Drug dosing and combinations differed among studies.

The composite endpoint of cardiac death, myocardial infarction, unstable angina, congestive heart failure, and new-onset atrial fibrillation occurred among fewer preoperative epidural recipients (relative risk [RR], 0.30; 95% CI, 0.14-0.63; I², 0%).

One study reported reduced ischemic episodes during surgery (P =.005) and less ischemic burden (P =.002) among the preoperative epidural group.

Mortality due to myocardial infarction, congestive heart failure, or arrhythmia during a 3-year follow-up was lower among the preoperative epidural cohort (RR, 0.13; 95% CI, 0.02-0.98; I², 0%).

In sensitivity analyses, however, the epidural treatment was no longer associated with decreased cardiac events (RR, 0.40; 95% CI, 0.16-1.01; I², 62%) or mortality (RR, 0.43; 95% CI, 0.08-2.39; I², 48%).

There were insufficient data to perform meta-analyses for the outcomes of cardiac events or mortality.

For pain, 1 study found that epidural recipients had a higher response rate (100%; P =.001) compared with continuous block (86.7%) or intravenous medications (46.7%), and fewer patients who received an epidural required rescue analgesia (P =.02). Another study reported that the epidural was associated with reduced mean postoperative (37.1%) and perioperative (35.1%) pain scores (P =.006).

Adverse effects of itching (P =.28), nausea (P =.48), or sleep quality (P =.51) did not differ significantly between intervention groups in 1 study. Another study reported a higher dropout rate (57.1%) among the epidural recipients.

This analysis was limited by the few studies that met the investigators’ inclusion criteria, causing their meta-analysis to be underpowered.

These data indicated preoperative epidural analgesia for patients with hip fractures may be associated with decreased cardiac events and mortality. Potentially the epidural may be able to reduce pain more effectively without increasing adverse events. Additional studies are needed to confirm these observations.

Reference

Choi JV, Cheung RM, Mozel MR, Merchant RN, Lee SM. Perioperative outcomes following preoperative epidural analgesia in hip fracture patients undergoing surgical repair: a systematic review. Pain Med. Published online May 22, 2021. doi:10.1093/pm/pnab176