Comparison of outcomes of using spinal versus general anesthesia in total hip arthroplasty.
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Blood loss, operative time, and rate of complications were compared in 606 patients undergoing primary unilateral total hip arthroplasty with either spinal anesthesia (SA) or general anesthesia (GA). Patients were followed for 2 years after surgery. Compared with GA, SA resulted in mean reductions of 12% in operative time, 25% in estimated intraoperative blood loss, 38% in rate of operative blood loss, and 50% in intraoperative transfusion requirements. Compared with patients receiving GA, patients receiving SA had higher hemoglobin levels on postoperative days 1 and 2 and a 20% lower total transfusion requirement. SA appears superior to GA for this procedure.Keywords:
Blood management
Hip Arthroplasty
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The effects of continuous epidural anesthesia and of general anesthesia on the incidence of thromboembolism following total hip replacement were studied. Sixty patients were randomly allotted to one of two groups receiving either epidural or general anesthesia. Epidural anesthesia (N = 30) consisted of 0.5% bupivacaine with epinephrine intraoperatively; for pain relief in the postoperative period (24 h), 0.25% bupivacaine with epinephrine was given every 3 h. General anesthesia (N = 30) consisted of controlled ventilation with N2O-O2 and intravenous fentanyl and pancuronium bromide; postoperatively, narcotic analgesics were given intramuscularly on demand for pain relief. Significantly lower frequencies were found following epidural anesthesia than after general anesthesia in deep venous thrombosis involving the popliteal and femoral veins (13% and 67%, respectively), deep venous thrombosis involving both calf and thigh veins (40% and 77%), and pulmonary embolism (10% and 33%). Possible explanations for these differences include increased circulation in the lower extremities, less tendency for intravascular clotting to occur, and more efficient fibrinolysis in association with continuous epidural anesthesia. The decrease in blood loss associated with epidural anesthesia with lower transfusion requirements also might play a role. Epidural analgesia prolonged into the postoperative period, in addition to other appropriate thromboprophylactic measures, should be of value in patients undergoing operations associated with a high risk of thromboembolic complications.
Narcotic
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Purpose: We analyzed the results of patients who underwent percutaneous nephrolithotomy (PCNL) for management of kidney stone disease under combined spinal-epidural anesthesia and compared surgical parameters and outcomes with a matched control group who underwent PCNL under general anesthesia. Patients and Methods: A total of 82 patients were studied in two groups. Group 1 (n = 45) consisted of the patients who underwent general anesthesia, and group 2 (n = 37) comprised those who received combined spinal-epidural anesthesia. Results: The mean ages of patients in groups 1 and 2 were 45 ± 15 and 44 ± 15 years, respectively. The mean areas of the stones in groups 1 and 2 were 734 ± 386 mm2 and 731 ± 394 mm2, respectively. There were no significant differences between groups 1 and 2 among surgical parameters, including age, stone area, operative time, irrigation fluids, fluoroscopy time, delta hemoglobin, and hospitalization time (P = 0.439). At the end of the surgery, stone-free rates were 76% in group 1 and 81% in group 2; clinically insignificant residue fragments rates were 24% in group 1 and 19% in group 2. The difference was statistically insignificant between the groups (P = 0.543). Conclusions: We consider that combined spinal-regional anesthesia is a feasible technique in PCNL operations because the efficacy and safety were not affected. Further investigations with larger series are needed.
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Background: Spinal anesthesia has been associated with lower postoperative rates of deep-vein thrombosis, a shorter operative time, and less blood loss when compared with general anesthesia. The purpose of the present study was to identify differences in thirty-day perioperative morbidity and mortality between anesthesia choices among patients undergoing total knee arthroplasty. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was searched to identify patients who underwent primary total knee arthroplasty between 2005 and 2010. Complications that occurred within thirty days after the procedure in patients who had been managed with either general or spinal anesthesia were identified. Patient characteristics, thirty-day complication rates, and mortality were compared. Multivariate logistic regression identified predictors of thirty-day morbidity, and stratified propensity scores were used to adjust for selection bias. Results: The database search identified 14,052 cases of primary total knee arthroplasty; 6030 (42.9%) were performed with the patient under spinal anesthesia and 8022 (57.1%) were performed with the patient under general anesthesia. The spinal anesthesia group had a lower unadjusted frequency of superficial wound infections (0.68% versus 0.92%; p = 0.0003), blood transfusions (5.02% versus 6.07%; p = 0.0086), and overall complications (10.72% versus 12.34%; p = 0.0032). The length of surgery (ninety-six versus 100 minutes; p < 0.0001) and the length of hospital stay (3.45 versus 3.77 days; p < 0.0001) were shorter in the spinal anesthesia group. After adjustment for potential confounders, the overall likelihood of complications was significantly higher in association with general anesthesia (odds ratio, 1.129; 95% confidence interval, 1.004 to 1.269). Patients with the highest number of preoperative comorbidities, as defined by propensity score-matched quintiles, demonstrated a significant difference between the groups with regard to the short-term complication rate (11.63% versus 15.28%; p = 0.0152). Age, female sex, black race, elevated creatinine, American Society of Anesthesiologists class, operative time, and anesthetic choice were all independent risk factors of short-term complication after total knee arthroplasty. Conclusions: Patients undergoing total knee arthroplasty who were managed with general anesthesia had a small but significant increase in the risk of complications as compared with patients who were managed with spinal anesthesia; the difference was greatest for patients with multiple comorbidities. Surgeons who perform knee arthroplasty may consider spinal anesthesia for patients with comorbidities. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Hip surgery
Spinal Surgery
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In Brief BACKGROUND: A recent meta-analysis showed that compared with general anesthesia (GA), neuraxial block reduced many serious complications in patients undergoing various types of surgeries. It is not known whether this finding from studying heterogeneous patient groups is applicable to a particular surgical patient population. We performed the present meta-analysis to determine whether anesthesia choice affected the outcome after elective total hip replacement (THR). METHODS: Medline (1966 to August 2005), MD Consult (1966 to August 2005), BIOSIS (1969 to August 2005), and EMBASE (1969 to August 2005) databases were searched. Randomized and quasirandomized studies comparing GA and neuraxial (spinal or epidural) block for elective THR were included in this analysis. RESULTS: Ten independent trials, involving 330 patients under GA and 348 patients under neuraxial block, were identified and analyzed. Pooled results from five trials showed that neuraxial block significantly decreased the incidence of radiographically diagnosed deep venous thrombosis or pulmonary embolism. The odds ratio (OR) for deep venous thrombosis was 0.27 with 95% confidence interval (CI) 0.17–0.42. The OR for pulmonary embolism was 0.26 with 95% CI 0.12–0.56. Neuraxial block also decreased the operative time by 7.1 min/case (95% CI 2.3–11.9 min) and intraoperative blood loss by 275 mL/case (95% CI 180–371 mL). Data from three trials showed that patients under neuraxial block for THR were less likely to require blood transfusion than were patients under GA (21/177 = 12% vs 62/188 = 33% of patients transfused, P < 0.001 by z-test). The OR for this comparison was 0.26. However, the CIs were wide and compatible with both no effect and a nine-tenths reduction (95% CI 0.06–1.05). CONCLUSIONS: Patients undergoing elective THR under neuraxial anesthesia seem to have better outcomes than those under GA. IMPLICATIONS: Elective total hip replacement under neuraxial block has a lower incidence of blood transfusion, deep venous thrombosis, and thromboembolic events than that under general anesthesia. Neuraxial block also reduces the operative time by 7.1 min/case and intraoperative blood loss by 275 mL/case.
Neuraxial Blockade
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A paucity of data exist on the use of critical care services (CCS) among hip and knee arthroplasty patients. The authors sought to identify the incidence and risk factors for the use of CCS among these patients and compare the characteristics and outcomes of patients who require CCS to those who do not.The authors analyzed hospital discharge data of patients who underwent primary hip or knee arthroplasty in approximately 400 United States hospitals between 2006 and 2010. Patient and healthcare system-related demographics for admitted patients requiring CCS were compared with those who did not. Differences in outcomes, including mortality, complications, disposition status, and hospital charges, were analyzed. Regression analysis was performed to identify risk factors for requiring CCS.A total of 528,495 patients underwent primary total hip (n = 172,467, 33%) and knee arthroplasty (n = 356,028, 67%). Of these, 3% required CCS. On average, CCS patients were older and had a higher comorbidity burden than did patients not requiring CCS. CCS patients experienced more complications, had longer hospital stays and higher costs, and were less likely to be discharged home than were non-CCS patients. Risk factors with increased odds for requiring CCS included advanced age, use of general versus neuraxial anesthesia, and the presence of postoperative cardiopulmonary complications.Approximately 1 of 30 patients undergoing total joint arthroplasty requires CCS. Given the large number of these procedures performed annually, anesthesiologists, orthopedic surgeons, critical care physicians, and administrators should be aware of the attendant risks this population represents and allocate resources accordingly.
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Abstract
Objectives: To obtain reliable estimates of the effects of neuraxial blockade with epidural or spinal anaesthesia on postoperative morbidity and mortality. Design: Systematic review of all trials with randomisation to intraoperative neuraxial blockade or not. Studies: 141 trials including 9559 patients for which data were available before 1 January 1997. Trials were eligible irrespective of their primary aims, concomitant use of general anaesthesia, publication status, or language. Trials were identified by extensive search methods, and substantial amounts of data were obtained or confirmed by correspondence with trialists. Main outcome measures: All cause mortality, deep vein thrombosis, pulmonary embolism, myocardial infarction, transfusion requirements, pneumonia, other infections, respiratory depression, and renal failure. Results: Overall mortality was reduced by about a third in patients allocated to neuraxial blockade (103 deaths/4871 patients versus 144/4688 patients, odds ratio=0.70, 95% confidence interval 0.54 to 0.90, P=0.006). Neuraxial blockade reduced the odds of deep vein thrombosis by 44%, pulmonary embolism by 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by 59% (all P<0.001). There were also reductions in myocardial infarction and renal failure. Although there was limited power to assess subgroup effects, the proportional reductions in mortality did not clearly differ by surgical group, type of blockade (epidural or spinal), or in those trials in which neuraxial blockade was combined with general anaesthesia compared with trials in which neuraxial blockade was used alone. Conclusions: Neuraxial blockade reduces postoperative mortality and other serious complications. The size of some of these benefits remains uncertain, and further research is required to determine whether these effects are due solely to benefits of neuraxial blockade or partly to avoidance of general anaesthesia. Nevertheless, these findings support more widespread use of neuraxial blockade.Neuraxial Blockade
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Total joint arthroplasty (TJA) patients often receive allogeneic blood transfusion. The use of regional anesthesia (RA) is thought to protect against the need for blood transfusion, but many randomized trials of RA in TJA have not reached this conclusion unanimously. We sought to describe the effect of RA on allogeneic transfusion in a large retrospective TJA series.We examined data from all TJAs performed in Edmonton, Alberta, in the year 2000 (n = 1875) and used logistic regression modelling to determine the relation between the use of RA and allogeneic transfusion.Twenty-eight percent of TJA subjects received an allogeneic transfusion. Transfusion was independently associated with increasing age, decreasing body mass, decreasing preoperative hemoglobin, female sex, increased comorbidity and prolonged operative time. After controlling for these factors, we found that the use of RA (in the form of spinal anesthesia) compared with general anesthesia reduced the odds ratio (OR) for transfusion to 0.729 (95% confidence interval [CI] 0.559-0.949). This represents the combination of a strong relation between RA and transfusion prevention in hip arthroplasty (OR 0.646, 95% CI 0.443-0.944) and a nonsignificant relation in knee arthroplasty (OR 0.825, 95% CI 0.564-1.208).The use of spinal anesthesia protects against allogeneic transfusion in arthroplasty of the hip but not the knee. This is consistent with what is known about the hemodynamic consequences of spinal anesthesia.
Transfusion medicine
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Total hip or knee replacement surgeries are common orthopedic interventions that can be performed with spinal anesthesia (SA) or general anesthesia (GA). No study has investigated the economic aspects associated with the two anesthetic techniques for this common surgery. We randomized 40 patients to receive either SA or GA and analyzed the drug and supply costs for anesthesia und recovery. Anesthesia-related times, hemodynamic variables, and pain scores were also recorded. Total costs per case without personnel costs were almost half in the SA group compared with the GA group; this was a result of less cost for anesthesia (P < 0.01) and for recovery (P < 0.05). This finding was supported by a sensitivity analysis. There were no relevant differences regarding anesthesia-related times. Patients in the GA group were admitted to the postanesthesia care unit with a higher pain score and needed more analgesics than patients in the SA group (both P < 0.01). We conclude that SA is a more cost-effective alternative to GA in patients undergoing hip or knee replacement, as it is associated with lower fixed and variable costs. Moreover, SA seems to be more effective, as patients in the SA group showed lower postoperative pain scores during their stay in the postanesthesia care unit.
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Epidural or spinal anesthesia involves several mechanisms hypothesized to reduce risk of surgical site infections (SSIs) during this decisive period. This study aims to compare the risk of SSI within 30 days of surgery for patients receiving total hip or knee replacement under general anesthesia versus those under epidural or spinal anesthesia.We used the Longitudinal Health Insurance Database of Taiwan. A total of 3,081 patients who underwent primary total hip or knee replacement from 2002 to 2006 were included in the study. Multivariate logistic regression and propensity score analyses were carried out to explore the relationship between method of surgical anesthesia and SSI occurring within 30 days of surgery.Of the 3,081 sampled patients, 56 patients (1.8%) had 30-day SSIs; 33 (2.8% of all under general anesthesia) of them had general anesthesia, and 23 (1.2% of all under epidural or spinal anesthesia) had epidural or spinal anesthesia (P = 0.002). The odds of SSI for patients receiving total hip or knee replacement under general anesthesia were 2.21 (95% CI = 1.25-3.90, P = 0.007) times higher than those who had the same procedure under epidural or spinal anesthesia, after adjusting for the patient's age, sex, the year of surgery, comorbidities, surgeon's age, and hospital teaching status.Total hip or knee replacement under general anesthesia is associated with higher risk of SSI compared with epidural or spinal anesthesia. Our results support the evolving concept of long-term consequences of anesthesia and emphasize the anesthesiologist's role in preventing SSIs.
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