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Calkins TE, Johnson EP, Eason RR, Mihalko WM, Ford MC. Spinal Versus General Anesthesia for Outpatient Total Hip and Knee Arthroplasty in the Ambulatory Surgery Center: A Matched-Cohort Study. J Arthroplasty 2024; 39:1463-1467. [PMID: 38103803 DOI: 10.1016/j.arth.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/12/2023] [Accepted: 12/12/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Spinal anesthesia is the predominant regimen in outpatient total joint arthroplasty (TJA), but induction often is unsuccessful, unobtainable, or against patient preference. We compared outcomes of same-day discharge (SDD) TJA with spinal versus general anesthesia in a free-standing ambulatory surgery center (ASC). METHODS We took 105 general anesthesia TJA and one-to-one nearest-neighbor matched them to 105 spinal anesthesia TJA over 7 years at 1 ASC. The rate of successful SDD, minutes to discharge, postoperative pain and nausea, and 90-day complications were compared. Postanesthesia care unit outcomes were additionally stratified by spinal anesthetic (mepivacaine versus bupivacaine). RESULTS All spinal anesthetic patients underwent SDD compared with 103 (98%) general anesthetic patients (P = .498). Mepivacaine spinal anesthesia patients spent the fewest minutes in postanesthesia care unit prior to discharge from the facility (206), followed by general anesthesia (227), and bupivacaine spinal anesthesia (291; P < .001). General anesthesia patients had the highest levels of pain at 1 hour (5.2 versus 1.5 versus 1.5) and 2 hours (3.2 versus 2.0 versus 1.3) postoperatively, and rates of nausea (48 versus 22 versus 28%) compared with mepivacaine and bupivacaine spinal anesthesia, respectively. The 90-day complications (6 versus 7), admissions (1 versus 3), and reoperations (5 versus 2) were similar among spinal and general anesthesia, respectively (P ≥ .445). CONCLUSIONS Both spinal and general anesthesia led to reliable SDD with similar 90-day complication rates. General anesthesia facilitated faster discharge from the ASC compared with bupivacaine spinal anesthesia but led to higher levels of pain and incidence of nausea postoperatively. LEVEL OF EVIDENCE Level 3, Retrospective Cohort Comparison.
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Affiliation(s)
- Tyler E Calkins
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Evan P Johnson
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Robert R Eason
- University of Tennessee Health Science Center, College of Medicine, Memphis, Tennessee
| | - William M Mihalko
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Marcus C Ford
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, University of Tennessee Health Science Center, Memphis, Tennessee
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Harris AB, Valenzuela J, Andrade N, Agarwal A, Gu A, Golladay G, Thakkar S. Comparison of Pneumonia and Major Complications After Total Joint Arthroplasty With Spinal Versus General Anesthesia: A Propensity-matched Cohort Analysis. J Am Acad Orthop Surg 2024; 32:33-40. [PMID: 37603703 DOI: 10.5435/jaaos-d-23-00192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/05/2023] [Indexed: 08/23/2023] Open
Abstract
INTRODUCTION Spinal anesthesia (SA) allows total joint arthroplasty to be done while minimizing opioids and systemic anesthetic agents compared with general anesthesia (GA). SA has been associated with shortened postoperative recovery; however, the relationship between SA, major postoperative complications, and pneumonia (PNA) remains unclear. METHODS Patients in a large, national database who underwent total hip arthroplasty or total knee arthroplasty from 2010 to 2020 were identified. 1:1 propensity score matching was used to create matched groups of patients who underwent SA and GA. The groups were matched by age, sex, chronic obstructive pulmonary disease, smoking status, Charlson Comorbidity Index, and American Society of Anesthesiology (ASA) classification. 1:1 matching was also done among the ASA classifications as a subanalysis. RESULTS Overall, equally matched groups of 217,267 patients who underwent SA versus GA were identified. 850 patients (0.39%) developed postoperative PNA after GA versus 544 patients (0.25%) after SA ( P < 0.001). The risk of major complications was 6,922 (3.2%) in the GA group and 5,401 (2.5%) in the SA group ( P < 0.001). Similarly, the risk of unplanned postoperative reintubation was higher (0.18% versus 0.10%, P < 0.001) and mortality was higher (0.14% versus 0.09%, P < 0.001) in the GA group than in the SA group. In ASA 1 to 3 patients, the risk of PNA was 0.08% to 0.21% higher with GA than with SA. In ASA 4 patients, the risk of PNA was 0.42% higher in SA than in GA (1.92% versus 1.5%, P < 0.001) and the mortality rate was nearly doubled in GA than in SA (1.46% versus 0.77%, P = 0.017). DISCUSSION Overall, GA was associated with a small but markedly higher rate of major complications, mortality, and PNA than SA in patients undergoing total joint arthroplasty when matching for differences in comorbidities. ASA 4 patients experienced the greatest increase in absolute risk of mortality with GA versus SA.
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Affiliation(s)
- Andrew B Harris
- From the Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD (Harris, and Thakkar), the California Health Sciences University, Clovis, CA (Valenzuela), the Department of Anesthesiology, Johns Hopkins Hospital, Baltimore, MD (Andrade), the Department of Orthopaedic Surgery, The George Washington University, Washington, DC (Agarwal, and Gu), the Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA (Golladay), and the Orthopaedics Research Collaborative (ORC) (Harris, Gu, Golladay, and Thakkar)
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Issa M, Naja A, Ghanem A, Shayya S, Noufi P, Faddoul A, Saghieh S. Regional versus general anesthesia in knee arthroplasty in patients with different classes of BMI: A matched analysis of the NSQIP database. J Orthop Sci 2024; 29:188-193. [PMID: 36464543 DOI: 10.1016/j.jos.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 10/21/2022] [Accepted: 11/03/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Knee arthroplasty for knee arthritis is a commonly performed surgery yielding excellent functional results and good pain relief. It is associated with post-surgical complications according to the type of anesthesia and BMI class. METHODS The National Surgical Quality Improvement Project database for the years 2005-2012 for patients >18 years of age who underwent knee arthroplasty, condyle and plateau, medial and/or lateral compartment. The surgical site complications, bleeding occurrences necessitating transfusion, unplanned readmissions, and mortality stratified according to anesthesia type and BMI class over a period of 30-days were examined. RESULTS A total of 78,275 patients were included for analysis; regional anesthesia showed a consistent protective effect from surgical site complications more prominent with increasing obesity class with respective ORs and their corresponding 95% CI for pre-obesity, class I, II, and III obesity being 0.95 [0.89-1.09], 0.75 [0.68-0.83], 0.64 [0.57-0.72], and 0.61 [0.54-0.7]. CONCLUSIONS Higher BMI values are a protective factor for the risk of bleeding requiring transfusion in patients undergoing total knee arthroplasty. Moreover, regional anesthesia is the preferred choice of anesthesia as well if postoperative complications are considered. A significant decrease in the rate of post-operative blood transfusions was seen in patients with high BMI and regional anesthesia.
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Affiliation(s)
- Mohamad Issa
- Division of Orthopaedic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ahmad Naja
- Division of Orthopaedic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Anthony Ghanem
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Sami Shayya
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Paul Noufi
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Annibal Faddoul
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Said Saghieh
- Division of Orthopaedic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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Knio ZO, Clancy PW, Zuo Z. Effect of spinal versus general anesthesia on thirty-day outcomes following total hip arthroplasty: A matched-pair cohort analysis. J Clin Anesth 2023; 87:111083. [PMID: 36848778 DOI: 10.1016/j.jclinane.2023.111083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/17/2023] [Indexed: 02/27/2023]
Abstract
STUDY OBJECTIVE It has not yet been established whether total hip arthroplasty complications are associated with anesthetic technique (spinal versus general). This study assessed the effect of spinal versus general anesthesia on health care resource utilization and secondary endpoints following total hip arthroplasty. DESIGN Propensity-matched cohort analysis. SETTING American College of Surgeons National Surgical Quality Improvement Program participating hospitals from 2015 to 2021. PATIENTS Patients undergoing elective total hip arthroplasty (n = 223,060). INTERVENTIONS None. MEASUREMENTS The a priori study duration was 2015 to 2018 (n = 109,830). The primary endpoint was 30-day unplanned resource utilization, namely readmission and reoperation. Secondary endpoints included 30-day wound complications, systemic complications, bleeding events, and mortality. The impact of anesthetic technique was investigated with univariate analyses, multivariable analyses, and survival analyses. MAIN RESULTS The 1:1 propensity-matched cohort included 96,880 total patients (48,440 in each anesthesia group) from 2015 to 2018. On univariate analysis, spinal anesthesia was associated with a lower incidence of unplanned resource utilization (3.1% [1486/48440] vs 3.7% [1770/48440]; odds ratio [OR], 0.83 [95% CI, 0.78 to 0.90]; P < .001), systemic complications (1.1% [520/48440] vs 1.5% [723/48440]; OR, 0.72 [95% CI, 0.64 to 0.80]; P < .001), and bleeding events requiring transfusion (2.3% [1120/48440] vs 4.9% [2390/48440]; OR, 0.46 [95% CI, 0.42 to 0.49]; P < .001). On multivariable analysis, spinal anesthesia remained an independent predictor of unplanned resource utilization (adjusted odds ratio [AOR], 0.84 [95% CI, 0.78 to 0.90]; c = 0.646), systemic complications (AOR, 0.72 [95% CI, 0.64 to 0.81]; c = 0.676), and bleeding events (AOR, 0.46 [95% CI, 0.42 to 0.49]; c = 0.686). Hospital length of stay was also shorter in the spinal anesthesia cohort (2.15 vs 2.24 days; mean difference, -0.09 [95% CI, -0.12 to -0.07]; P < .001). Similar findings were observed in the cohort from 2019 to 2021. CONCLUSIONS Total hip arthroplasty patients receiving spinal anesthesia experience favorable outcomes compared to propensity-matched general anesthesia patients.
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Affiliation(s)
- Ziyad O Knio
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America
| | - Paul W Clancy
- School of Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America.
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Echeverri Lombana MDLP, Sanín Hoyos A, Echeverri Mallarino V, García Peña Á, Gomar Sancho C. Spinal anesthesia does not cause left ventricular dysfunction in patients older than 60 years without cardiovascular disease. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:140-147. [PMID: 36842680 DOI: 10.1016/j.redare.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 01/10/2022] [Indexed: 02/28/2023]
Abstract
BACKGROUND Elderly patients are undergoing surgery more frequently than ever. In this population, spinal anesthesia, which is known to cause sympathetic blockade associated with arterial vasodilation, is proposed as an excellent option. However, its effects on left ventricular systolic function have not been studied. OBJECTIVES To evaluate left ventricular systolic function by transthoracic echocardiography in patients older than 60 years, without prior cardiovascular disease, under spinal anesthesia. PATIENTS AND METHODS Prospective observational study with a total of 54 patients older than 60 years without prior cardiovascular disease, in whom, after the completion of subarachnoid anesthesia with hyperbaric 0.5% bupivacaine with sensory block equal to or greater than T10, left ventricular systolic function was measured using MAPSE. In addition, CI-IVC, LVOT-VTI and CO were measured. Values at 5 min after the blockade were compared with those obtained previously. RESULTS A 3.3% decrease in MAPSE and a slight decrease in LVOT-VTI and CO were found, with no statistical or clinical significance. 14.8% of the patients presented MAP equal to or less than 60 mmHg. Comparison of echocardiographic changes between hypotensive and non-hypotensive patients was not statistically significant or clinically relevant. DISCUSSION Our study shows that spinal anesthesia with anesthetic level T10 or higher in patients older than 60 years without cardiovascular disease is a safe technique since it does not significantly alter echocardiographic parameters measuring left ventricular systolic function.
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Affiliation(s)
- M de la P Echeverri Lombana
- Departamento de Anestesiología, Hospital Universitario San Ignacio, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia.
| | - A Sanín Hoyos
- Departamento de Anestesiología, Hospital Universitario San Ignacio, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - V Echeverri Mallarino
- Departamento de Anestesiología, Hospital Universitario San Ignacio, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Á García Peña
- Departamento de Cardiología, Hospital Universitario San Ignacio, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - C Gomar Sancho
- Universidad de Barcelona y Universidad de Manresa, GRinDoSSeP, Spain
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Bian T, Zhang L, Man S, Li H, Dou Y, Zhou Y. Predisposing factors for allogeneic blood transfusion in patients with ankylosing spondylitis undergoing primary unilateral total hip arthroplasty: a retrospective study. J Orthop Surg Res 2023; 18:9. [PMID: 36597109 PMCID: PMC9811782 DOI: 10.1186/s13018-022-03464-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 12/20/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The transfusion rate is relatively high in patients with ankylosing spondylitis (AS) undergoing total hip arthroplasty (THA). However, relevant studies focusing on the predisposing factors for transfusion with a large sample size are lacking. This study aimed to investigate the incidence of and risk factors for allogeneic blood transfusion in patients with AS undergoing primary unilateral THA. METHODS This retrospective study included 331 patients with AS who underwent primary unilateral THA between 2011 and 2021. Relevant parameters were collected through a chart review. Multivariate logistic regression analysis was conducted to identify possible factors associated with perioperative allogeneic blood transfusion. RESULTS A total of 113 (34.1%) patients received perioperative allogeneic blood transfusions. Factors related to receiving an allogeneic blood transfusion included prolonged operative duration (odds ratio [OR] per 10 min = 1.139, P = 0.047), increased estimated intraoperative blood loss (OR per 100 mL = 1.348, P < 0.001), and increased postoperative drainage volume (OR per 100 mL = 1.235, P = 0.024). A higher body mass index (BMI) (OR = 0.914, P = 0.012), perioperative tranexamic acid (TXA) use (OR = 0.166, P < 0.001), and a higher preoperative hemoglobin level (OR per 1 g/dL = 0.744, P = 0.004) decreased the risk of transfusion. CONCLUSIONS In patients with AS undergoing THA, prolonged operative duration, increased estimated intraoperative blood loss, and increased postoperative drainage volume were found to be risk factors for transfusion, whereas a higher BMI, perioperative TXA use, and a higher preoperative hemoglobin level were protective factors. These results may aid in developing a better perioperative management strategy, ultimately reducing the need for transfusion.
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Affiliation(s)
- Tao Bian
- grid.11135.370000 0001 2256 9319Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035 China
| | - Liang Zhang
- grid.11135.370000 0001 2256 9319Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035 China
| | - Siliang Man
- grid.11135.370000 0001 2256 9319Department of Rheumatology and Immunology, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035 China
| | - Hongchao Li
- grid.11135.370000 0001 2256 9319Department of Rheumatology and Immunology, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035 China
| | - Yong Dou
- grid.11135.370000 0001 2256 9319Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035 China
| | - Yixin Zhou
- grid.11135.370000 0001 2256 9319Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035 China
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Owen AR, Amundson AW, Fruth KM, Duncan CM, Smith HM, Johnson RL, Taunton MJ, Pagnano MW, Berry DJ, Abdel MP. Spinal Compared with General Anesthesia in Contemporary Primary Total Hip Arthroplasties. J Bone Joint Surg Am 2022; 104:1542-1547. [PMID: 35726967 DOI: 10.2106/jbjs.22.00280] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The specific advantages of spinal anesthesia compared with general anesthesia for primary total hip arthroplasty (THA) remains unknown. Therefore, this study aimed to investigate the pain control, length of stay, and postoperative outcomes associated with spinal anesthesia compared with general anesthesia in a large cohort of primary THAs from a single, high-volume academic institution. METHODS We retrospectively identified 13,730 primary THAs (11,319 patients) from 2001 to 2016 using our total joint registry. Of these cases, 58% had general anesthesia and 42% had spinal anesthesia. The demographic characteristics were similar between groups, with mean age of 64 years, 51% female, and mean body mass index (BMI) of 31 kg/m 2 . Data were analyzed using an inverse probability of treatment weighted model based on a propensity score that accounted for numerous patient and operative factors. The mean follow-up was 6 years. RESULTS Patients treated with spinal anesthesia had lower Numeric Pain Rating Scale (NPRS) scores (p < 0.001) and required fewer postoperative oral morphine equivalents (OMEs) at all time points evaluated (p < 0.001). Patients treated with spinal anesthesia also had shorter hospital length of stay (p = 0.02), fewer altered mental status events (odds ratio [OR], 0.7; p = 0.02), and fewer intensive care unit (ICU) admissions (OR, 0.7; p = 0.01). There was no difference in the incidence of deep vein thrombosis (p = 0.8), pulmonary embolism (p = 0.4), 30-day readmissions (p = 0.17), 90-day readmissions (p = 0.18), all-cause revisions (p = 0.17), or all-cause reoperations (p = 0.14). CONCLUSIONS In this large, single-institution study, we found that spinal anesthesia was associated with reduced pain scores and OME use postoperatively. Furthermore, spinal anesthesia resulted in fewer altered mental status events and ICU admissions. These data favor the use of spinal anesthesia in primary THAs. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Aaron R Owen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Adam W Amundson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kristin M Fruth
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Christopher M Duncan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hugh M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Mark W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Combs DB, Hummel A, Nishioka ST, Andrews SN, Nakasone CK. Reducing transfusion in hip arthroplasty: tranexemic acid diminishes influence of anesthesia administered. Arch Orthop Trauma Surg 2022; 143:3535-3540. [PMID: 35996031 DOI: 10.1007/s00402-022-04591-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The risk of transfusion following total hip arthroplasty (THA) continues to be problematic. The best choice of anesthesia (spinal vs general) and impact of tranexamic acid (TXA) use in reducing transfusions following surgery remain unclear. Therefore, the purpose of this study was to compare rates of blood transfusion following THA via the anterior approach using three different anesthesia protocols with and without TXA. MATERIALS AND METHODS This retrospective review included 1399 patients (1659 hips), receiving spinal anesthesia (SA) without (248 patients) and with TXA (77 patients), general anesthesia (GA) without (151 patients) and with TXA (171) and general anesthesia with paravertebral block (GA-PVB) and TXA (748 patients). All procedures were performed by a single surgeon. Chi-Squared tests and logistic regression were performed to evaluate the rate and risks of transfusion between groups. RESULTS Without TXA, transfusion rate with GA (24.5%) was higher than SA (13.4%) (p = 0.004). With TXA, there was no difference in transfusion rates between GA (4.6%), SA (3.9%) or GA-PVB (4.0%). The multivariable regression revealed bilateral (Odds Ratio (OR): 6.473; p < 0.001), female (OR: 2.046; p = 0.004), age (OR: 1.028; p = 0.012) and pre-operative anemia (OR: 2.604; p < 0.001) as increasing the risk of transfusion while use of TXA (OR: 0.168; p < 0.001) significantly reduced transfusion risk. CONCLUSION The use of TXA during THA via the anterior approach removed the influence of anesthesia type regarding risk of transfusion. The use of TXA may reverse presumed disadvantages of GA alone, potentially facilitating rapid discharge following surgery.
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Affiliation(s)
- Dylan B Combs
- John A Burns School of Medicine, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Amelia Hummel
- John A Burns School of Medicine, 651 Ilalo Street, Honolulu, HI, 96813, USA
| | - Scott T Nishioka
- John A Burns School of Medicine, 651 Ilalo Street, Honolulu, HI, 96813, USA.,Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96818, USA
| | - Samantha N Andrews
- Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96818, USA. .,Department of Surgery, University of Hawai'I, 1356 Lusitana Street, Honolulu, HI, 96813, USA.
| | - Cass K Nakasone
- Straub Medical Center, Bone and Joint Center, 888 South King Street, Honolulu, HI, 96818, USA.,Department of Surgery, University of Hawai'I, 1356 Lusitana Street, Honolulu, HI, 96813, USA
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9
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Wei C, Gu A, Muthiah A, Fassihi SC, Sculco PK, Nunley RM, Bernstein BA, Liu J, Berger JS. Neuraxial anaesthesia is associated with improved outcomes and reduced postoperative complications in patients undergoing aseptic revision total hip arthroplasty. Hip Int 2022; 32:221-230. [PMID: 33241947 DOI: 10.1177/1120700020975749] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND As the incidence of primary total hip arthroplasty (THA) continues to increase, revision THA (rTHA) is becoming an increasingly common procedure. rTHA is widely regarded as a more challenging procedure, with higher complication rates and increased medical, social and economic burdens when compared to its primary counterpart. Given the complexity of rTHA and the projected increase in incidence of these procedures, patient optimisation is becoming of interest to improve outcomes. Anaesthetic choice has been extensively studied in primary THA as a modifiable risk factor for postoperative outcomes, showing favourable results for neuraxial anaesthesia compared to general anaesthesia. The impact of anaesthetic choice in rTHA has not been studied previously. METHODS A retrospective study was performed using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent rTHA between 2014 and 2017 were divided into 3 anaesthesia cohorts: general anaesthesia, neuraxial anaesthesia, and combined general-regional (neuraxial and/or peripheral nerve block) anaesthesia. Univariate and multivariate analyses were used to analyse patient characteristics and 30-day postoperative outcomes. Bonferroni correction was applied for post-hoc analysis. RESULTS In total, 5759 patients were identified. Of these, 3551 (61.7%) patients underwent general anaesthesia, 1513 (26.3%) patients underwent neuraxial anaesthesia, and 695 (12.1%) patients underwent combined general-regional anaesthesia. On multivariate analysis, neuraxial anaesthesia was associated with decreased odds for any-one complication (OR 0.635; p < 0.001), perioperative blood transfusion (OR 0.641; p < 0.001), and extended length of stay (OR 0.005; p = 0.005) compared to general anaesthesia. CONCLUSIONS Relative to those receiving general anaesthesia, patients undergoing neuraxial anaesthesia are at decreased risk for postoperative complications, perioperative blood transfusions, and extended length of stay. Prospective controlled trials should be conducted to verify these findings.
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Affiliation(s)
- Chapman Wei
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Alex Gu
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Arun Muthiah
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Safa C Fassihi
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington DC, USA
| | - Peter K Sculco
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University at St Louis, St. Louis, MO
| | - Brad A Bernstein
- Department of Anesthesiology, St Louis University School of Medicine, St. Louis, MO, USA
| | - Jiabin Liu
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| | - Jeffrey S Berger
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Calkins TE, McClatchy SG, Rider CM, Toy PC. Mepivacaine vs Bupivacaine Spinal Anesthesia in Total Hip Arthroplasty at an Ambulatory Surgery Center. J Arthroplasty 2021; 36:3676-3680. [PMID: 34392991 DOI: 10.1016/j.arth.2021.07.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/08/2021] [Accepted: 07/25/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Mepivacaine spinal anesthetic may facilitate more rapid postoperative recovery in joint arthroplasty than bupivacaine. This study compared recovery, pain, and complications between the 2 anesthetics in anterior-approach total hip arthroplasty (THA) at a free-standing ambulatory surgery center (ASC). METHODS This retrospective cohort study of 282 consecutive patients with mean age 55.7 ± 8.8 years and body mass index 30.6 ± 5.3 who underwent THA at an ASC from November 2018 to July 2020 compares mepivacaine (n = 141) vs bupivacaine (n = 141) spinal anesthesia, a transition made in March 2019. The main outcomes were length of stay in the postoperative unit (post acute care unit) prior to same-day discharge (SDD), time to controlled void, and ambulation. Secondarily, postoperative pain scores (0-10) with morphine equivalents were required and any postoperative complications were compared. RESULTS Mepivacaine decreased mean post acute care unit stay (4.0 vs 5.7 hours, P < .001), time to void (3.1 vs 4.9 hours, P < .001), and ambulation (3.2 vs 4.5 hours, P < .001). No patients needed urinary catheterization or overnight stay. Two patients in the bupivacaine group had transient neurologic symptoms, consisting of foot drop and spinal headache, compared to none with mepivacaine (P = .498). Mepivacaine patients had increased postoperative pain at 2 hours (1.7 vs 0.9, P < .001), at discharge (1.1 vs 0.5, P = .004), and morphine equivalent doses received (7.8 vs 3.7 mg, P < .001). CONCLUSION Mepivacaine spinal anesthesia for anterior-approach THA safely facilitated more rapid SDD from the ASC through decreased times to controlled void and ambulation with only minor increase in pain when compared to bupivacaine. LEVEL OF EVIDENCE Level III - Retrospective comparative cohort study.
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Affiliation(s)
- Tyler E Calkins
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN
| | - Samuel G McClatchy
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN
| | - Carson M Rider
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN
| | - Patrick C Toy
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN
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Liu J, Zhong H, DeMeo D, Do H, Kirksey M, Gonzalez Della Valle A, YaDeau J. Controlled hypotension during neuraxial anesthesia is not associated with increased odds of in-hospital common severe medical complications in patients undergoing elective primary total hip arthroplasty - A retrospective case control study. PLoS One 2021; 16:e0248419. [PMID: 33793596 PMCID: PMC8016238 DOI: 10.1371/journal.pone.0248419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/25/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction The use of controlled hypotension during neuraxial anesthesia for joint arthroplasty is controversial. We conducted a large institutional database analysis to assess common in-hospital complications and mortality of patients undergoing primary total hip arthroplasty (THA) under controlled hypotension and neuraxial anesthesia. Methods We conducted a large retrospective case control study of 11,292 patients who underwent primary THA using neuraxial anesthesia between March 2016 and May 2019 in a single institution devoted to musculoskeletal care. The degree and duration of various mean arterial pressure (MAP) thresholds were analyzed for adjusted odds ratios with composite common severe complications (in-hospital myocardial infarction, stroke, and/or acute kidney injury) as the primary outcome. Results Sixty-eight patients developed common severe complications (0.60%). Patients with complications were older (median age 75.6 vs 64.0 years) and had a higher American Society of Anesthesiologists (ASA) classification (45.6% vs 17.6% ASA III). The duration of hypotension at various MAP thresholds (45 to 70 mm Hg) was not associated with increasing odds of common severe medical complications. Conclusions Controlled hypotension (ranging from 45 to 70 mmHg) for a moderate duration during neuraxial anesthesia was not associated with increased odds of common severe complications (myocardial infarction, stroke, and/or acute kidney injury) among patients receiving neuraxial anesthesia for elective THA.
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Affiliation(s)
- Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, Weill Cornell Medical Center, New York, NY, United States of America
- * E-mail: (JL); (JY)
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, Weill Cornell Medical Center, New York, NY, United States of America
| | - Danya DeMeo
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, Weill Cornell Medical Center, New York, NY, United States of America
| | - Huong Do
- Clinical Data Core, Hospital for Special Surgery, New York, NY, United States of America
| | - Meghan Kirksey
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, Weill Cornell Medical Center, New York, NY, United States of America
| | - Alejandro Gonzalez Della Valle
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical Center, New York, NY, United States of America
| | - Jacques YaDeau
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, Weill Cornell Medical Center, New York, NY, United States of America
- * E-mail: (JL); (JY)
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12
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Eklund SE, Vodonos A, Ryan-Barnett SM. Changing practice to increase rates of spinal anaesthesia for total joint replacement. J Perioper Pract 2021; 32:83-89. [PMID: 33611968 DOI: 10.1177/1750458920970145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Neuraxial anaesthesia for lower extremity total joint replacement surgery has several advantages over general anaesthesia; however, we encountered resistance to routine use of spinal anaesthesia and standardised analgesic regimens at our large, tertiary hospital. Our Perioperative Surgical Home led to multidisciplinary education and enhanced communication to change practice, with the purpose of increasing rates of neuraxial anaesthetics for these surgeries. METHODS Team members from anaesthesia, nursing and surgery participated in the development and adoption of the care pathway. After implementation, we performed a retrospective analysis to examine the impact of the pathway on primary anaesthetic choice. Data were analysed using Student's t-test and interrupted time series analysis. RESULTS The rate of neuraxial anaesthetics increased following implementation of the total joint pathway. CONCLUSION With multidisciplinary collaboration, we were able to change practice towards spinal anaesthesia, despite a large and diverse group of practitioners.
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Affiliation(s)
- Susan E Eklund
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Alina Vodonos
- Clinical Research Center Soroka University Medical Center, Beersheva, Israel
| | - Sheila M Ryan-Barnett
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA
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Incidence, Risk Factors, and Nomogram of Transfusion and Associated Complications in Nonfracture Patients following Total Hip Arthroplasty. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2928945. [PMID: 33123567 PMCID: PMC7584933 DOI: 10.1155/2020/2928945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/13/2020] [Accepted: 10/03/2020] [Indexed: 11/17/2022]
Abstract
The incidence, risk factors, and associated complications of perioperative transfusion in nonfracture patients following total hip arthroplasty (THA) are unclear. The aim of the present research was to study the predictors of transfusion risk in nonfracture patients following THA and develop a nomogram. One thousand six hundred and thirty-five patients who underwent THA due to nonfracture disease in our institution between September 2013 and July 2017 were included. Independent predictors of transfusion were identified by univariate, LASSO, and multivariate analyses. A nomogram was established based on independent predictors. In addition, a prospective cohort was used to validate the nomogram. The area under the receiver operating characteristic curve was utilized to evaluate the discrimination of the nomogram. Calibration and decision curve analyses were established to evaluate the nomogram. In addition, the association between perioperative transfusion and 30- and 90-day complications was studied. The incidence of transfusion was 15.78%, and 10 independent predictors were confirmed. The areas under the curve of the nomogram were 0.834 and 0.867 in the training and validation cohorts, respectively. Moreover, the area under the curve of the nomogram was significantly higher than that of any single predictor in both the training and validation cohorts. Calibration curve and decision curve analyses in both the training and validation cohorts showed good performance of the nomogram. In addition, perioperative transfusion was identified as an independent risk factor for both 30- and 90-day complications. Generally, ten transfusion-related factors for nonfracture patients following THA were identified. A validated nomogram was established, and several adverse events were confirmed to be associated with transfusion.
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14
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Turcotte JJ, Stone AH, Gilmor RJ, Formica JW, King PJ. The Effect of Neuraxial Anesthesia on Postoperative Outcomes in Total Joint Arthroplasty With Rapid Recovery Protocols. J Arthroplasty 2020; 35:950-954. [PMID: 31883826 DOI: 10.1016/j.arth.2019.11.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/14/2019] [Accepted: 11/24/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Compared to general anesthesia (GA), neuraxial anesthesia (NA) has been associated with improved outcomes after total joint arthroplasty (TJA). We examined the impact of NA on patient outcomes in an institution with an established rapid recovery protocol. METHODS This is a single-institution retrospective analysis of 5914 consecutive primary TJA performed from July 2015 to June 2018. Univariate tests and multivariate regression compared length of stay (LOS), transfusion rates, hematocrit levels, discharge disposition, and emergency room returns between patients receiving GA and NA. RESULTS Patients receiving NA had a significantly shorter LOS (total hip arthroplasty [THA]: GA 1.74 vs NA 1.36 days, P < .001; total knee arthroplasty [TKA]: GA 1.77 vs NA 1.64 days, P < .001). Both THA and TKA patients receiving NA were less likely to require transfusion (THA: GA 5.8% vs NA 1.6%, P < .001; TKA: GA 2.5% vs NA 0.5%, P < .001) and had a higher postoperative hematocrit (THA: GA 32.50% vs NA 33.22%, P < .001; TKA GA 33.57 vs NA 34.50%, P < .001). Patients receiving NA were more likely to discharge home (THA: GA 83.4% vs NA 92.3%, P < .001; TKA: GA 83.3% vs NA 86.3%, P = .010) (THA: NA adjusted OR [aOR] 2.04, P < .001; TKA: NA aOR 1.23, P = .048) and had significantly lower rates of 90-day emergency room visits (THA: NA aOR 0.61, P = .005; TKA: NA aOR 0.74, P = .034). CONCLUSION NA appears to contribute to decreased LOS, short-term complications, and transfusions while facilitating home discharge following TKA and THA. These trends are consistent when controlling for patient-specific risk factors, suggesting NA may enhance outcomes for patients with increased age, body mass index, and comorbidities. LEVEL OF EVIDENCE Level III Retrospective Cohort Study.
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15
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Spinal Anesthesia Is Associated With Decreased Complications After Total Knee and Hip Arthroplasty. J Am Acad Orthop Surg 2020; 28:e213-e221. [PMID: 31478916 DOI: 10.5435/jaaos-d-19-00156] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We compared the following 30-day outcomes for total knee arthroplasty (TKA) and total hip arthroplasty in spinal anesthesia (SA) versus general anesthesia (GA) (1) mortality, (2) major and minor complication rates, and (3) discharge disposition. METHODS From 2011 to 2016, the American College of Surgeons National Surgical Quality Improvement Program database contained 45,871 SA total hip arthroplasties and 65,092 receiving GA. There were 80,077 SA TKAs and 103,003 GA TKAs. Adjusted multivariate logistic regression evaluated associations between anesthesia type and 30-day outcomes. RESULTS Anesthesia modality was not associated with 30-day mortality (P > 0.05). The GA cohorts were at a greater risk for any complication, major complications, and minor complications (P < 0.05). Patients who received GA were at an increased risk for nonhome discharge. CONCLUSION Patients who undergo total joint arthroplasty with SA experience fewer 30-day complications and are less likely to have a nonhome discharge than those with GA.
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16
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Pennestrì F, Maffulli N, Sirtori P, Perazzo P, Negrini F, Banfi G, Peretti GM. Blood management in fast-track orthopedic surgery: an evidence-based narrative review. J Orthop Surg Res 2019; 14:263. [PMID: 31429775 PMCID: PMC6701001 DOI: 10.1186/s13018-019-1296-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 07/25/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research. METHODS AND MATERIALS We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital. RESULTS Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction. CONCLUSION The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.
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Affiliation(s)
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Fisciano, Italy. .,San Giovanni di Dio e Ruggi D'Aragona Hospital "Clinica Orthopedica" Department, Hospital of Salerno, Salerno, Italy. .,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, London, England.
| | - Paolo Sirtori
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Paolo Perazzo
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Francesco Negrini
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Giuseppe Banfi
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy.,Vita-Salute San Raffaele University, Scientific Direction, Milan, Italy
| | - Giuseppe M Peretti
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy.,University of Milan, Department of Biomedical Sciences for Health, Milan, Italy
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17
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Memtsoudis SG, Cozowicz C, Bekeris J, Bekere D, Liu J, Soffin EM, Mariano ER, Johnson RL, Hargett MJ, Lee BH, Wendel P, Brouillette M, Go G, Kim SJ, Baaklini L, Wetmore D, Hong G, Goto R, Jivanelli B, Argyra E, Barrington MJ, Borgeat A, De Andres J, Elkassabany NM, Gautier PE, Gerner P, Gonzalez Della Valle A, Goytizolo E, Kessler P, Kopp SL, Lavand'Homme P, MacLean CH, Mantilla CB, MacIsaac D, McLawhorn A, Neal JM, Parks M, Parvizi J, Pichler L, Poeran J, Poultsides LA, Sites BD, Stundner O, Sun EC, Viscusi ER, Votta-Velis EG, Wu CL, Ya Deau JT, Sharrock NE. Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis. Br J Anaesth 2019; 123:269-287. [PMID: 31351590 DOI: 10.1016/j.bja.2019.05.042] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/02/2019] [Accepted: 05/20/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes. METHODS The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations. RESULTS The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87. CONCLUSIONS Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation. RECOMMENDATION neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty. TRIAL REGISTRY NUMBER PROSPERO CRD42018099935.
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MESH Headings
- Anesthesia, Epidural/adverse effects
- Anesthesia, Epidural/mortality
- Anesthesia, General/adverse effects
- Anesthesia, General/mortality
- Anesthesia, Spinal/adverse effects
- Anesthesia, Spinal/mortality
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Hip/mortality
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Knee/mortality
- Evidence-Based Medicine/methods
- Humans
- Postoperative Complications/mortality
- Randomized Controlled Trials as Topic
- Treatment Outcome
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Affiliation(s)
- Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.
| | - Crispiana Cozowicz
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Janis Bekeris
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Dace Bekere
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Edward R Mariano
- Department of Anesthesia, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary J Hargett
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Bradley H Lee
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Pamela Wendel
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Mark Brouillette
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - George Go
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Sang J Kim
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Lila Baaklini
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Douglas Wetmore
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Genewoo Hong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Rie Goto
- Kim Barrett Memorial Library, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Bridget Jivanelli
- Kim Barrett Memorial Library, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Eriphyli Argyra
- Department of Anaesthesiology, Pain and Palliative Care, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael J Barrington
- Department of Medicine & Radiology, The University of Melbourne, Victoria, Australia
| | - Alain Borgeat
- Department of Anesthesiology and Intensive Care Medicine, Universität Zürich, Zurich, Switzerland
| | - Jose De Andres
- Anesthesia Unit- Surgical Specialties Department, Valencia University Medical School, Spain; Anesthesia, Critical Care, and Pain Management Department, General University Hospital, Valencia, Spain
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Philippe E Gautier
- Department of Anesthesiology, Clinique Ste-Anne St-Remi, Anderlecht, Belgium
| | - Peter Gerner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Alejandro Gonzalez Della Valle
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Enrique Goytizolo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Paul Kessler
- Department of Anesthesiology, Intensive Care and Pain Medicine, Orthopedic University Hospital, Frankfurt am Main, Germany
| | - Sandra L Kopp
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Catherine H MacLean
- Value Management Office, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Carlos B Mantilla
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel MacIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexander McLawhorn
- Department of Orthopedic Surgery, Hip and Knee Replacement, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Joseph M Neal
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael Parks
- Department of Orthopedic Surgery, Hip and Knee Replacement, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | | | - Lukas Pichler
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Jashvant Poeran
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery Science, New York, NY, USA
| | - Lazaros A Poultsides
- Department of Orthopaedic Surgery, New York Langone Orthopaedic Hospital, New York, NY, USA
| | - Brian D Sites
- Department of Anesthesiology, Dartmouth College Geisel School of Medicine, Hanover, NH, USA
| | - Otto Stundner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Eric C Sun
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Pain Center, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Effrossyni G Votta-Velis
- Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Jacques T Ya Deau
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Nigel E Sharrock
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
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Kyriakopoulos G, Oikonomou L, Panagopoulos A, Kotsarinis G, Vlachou M, Anastopoulos G, Kateros K. Transfusion rate, hospital stay and cost-effectiveness of intravenous or local administration of tranexamic acid in total hip and knee arthroplasty: A single-center randomized controlled clinical study. Orthop Rev (Pavia) 2019; 11:7866. [PMID: 31210910 PMCID: PMC6551458 DOI: 10.4081/or.2019.7866] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 05/02/2019] [Indexed: 01/12/2023] Open
Abstract
We have conducted a prospective randomized study to determine the effect of intravenous or local administration of tranexamic acid (TXA) in perioperative transfusion rates, hospital stay and overall hospitalization costs in patients underwent total knee (TKA) or total hip (THA) arthroplasty. During 2015-2016, 125 THA and 124 TKA consecutive patients were randomly allocated to receive low dose TXA either intravenously (ivTXA groups) or local administration (locTXA groups) or to serve as controls. Power analysis showed that 41 patients in each group were required in order to have an 80% probability of demonstrating a between surgeries difference of more than 35%. Full blood counts obtained on the first and third postoperative day and the maximum hemoglobin difference was documented in all patients. The costs of hospitalization, transfusions and TXA were retrieved by the hospital financial administration. All groups were homogenic in regards to age and preoperative Hgb levels. In both THA and TKA patients, a statistically significant reduction in the maximum hemoglobin difference was found for both the intravenous (ivTXA) and local application (locTXA) groups compared to controls (P<0.001). The average hospitalization was reduced by 2.2 and 2.9 days in THA and TKA patients in respect. The hospitalization costs for the control groups were higher both in THA (286 € more) and TKA (374 € more) patients. We were able to demonstrate that both intravenous and local administration of TXA can significantly reduce transfusion rate, hospital stay and overall cost in TKA or THA patients.
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Affiliation(s)
- Georgios Kyriakopoulos
- First Department of Trauma and Orthopedics, General Hospital of Athens "G. Gennimatas", Athens
| | - Leon Oikonomou
- First Department of Trauma and Orthopedics, General Hospital of Athens "G. Gennimatas", Athens
| | | | - Georgios Kotsarinis
- First Department of Trauma and Orthopedics, General Hospital of Athens "G. Gennimatas", Athens
| | - Maria Vlachou
- First Department of Trauma and Orthopedics, General Hospital of Athens "G. Gennimatas", Athens
| | - Georgios Anastopoulos
- First Department of Trauma and Orthopedics, General Hospital of Athens "G. Gennimatas", Athens
| | - Konstantinos Kateros
- First Department of Trauma and Orthopedics, General Hospital of Athens "G. Gennimatas", Athens
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Sharma BS, Swisher MW, Doan CN, Khatibi B, Gabriel RA. Predicting patients requiring discharge to post-acute care facilities following primary total hip replacement: Does anesthesia type play a role? J Clin Anesth 2018; 51:32-36. [PMID: 30075351 DOI: 10.1016/j.jclinane.2018.07.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/10/2018] [Accepted: 07/24/2018] [Indexed: 01/04/2023]
Abstract
STUDY OBJECTIVE We sought to develop a predictive model for discharge to post-acute care facilities in patients undergoing unilateral total hip replacement (THR). Furthermore, we sought to determine if the use of neuraxial anesthesia was an important covariate for the predictive model. DESIGN Retrospective observational study. SETTING Preoperative care and operating room at a single institution. PATIENTS Patients (n = 960) who underwent an elective primary THR between 2014 and 2016. INTERVENTIONS No intervention was performed. MEASUREMENTS We collected variables that were known preoperatively including age, sex, body mass index (BMI), preoperative opioid use, functional status based on metabolic equivalents (METS), preoperative anemia, thrombocytopenia, osteoarthritis and contralateral osteoarthritis grade, anesthesia type, comorbidities and surgical approach. We then performed multivariable logistic regression to develop a predictive model. MAIN RESULTS Female sex, preoperative opioid use, older age, general anesthesia, anemia, hypertension, a psychiatric diagnosis, use of dialysis, metabolic equivalents <4 and obesity are all risk factors for a post-acute facility discharge. The use of general anesthesia compared to neuraxial anesthesia was associated with increased odds (odds ratio 1.98, 95% confidence interval 1.31-3.00, p = 0.001) for post-acute facility discharge. Model performance was assessed using ten-fold cross-validation - the average area under the receiver operating characteristic curve calculated was 0.794. CONCLUSIONS We developed a predictive model for post-acute care facility discharge following THR. The use of neuraxial anesthesia was associated with decreased odds for post-acute care facility discharge.
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Affiliation(s)
- Beamy S Sharma
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States of America
| | - Matthew W Swisher
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States of America
| | - Christina N Doan
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States of America
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States of America
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States of America; Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, San Diego, CA, United States of America.
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20
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Reply to Drs Saxena and Loganathan. Reg Anesth Pain Med 2018; 43:647-648. [PMID: 30036319 DOI: 10.1097/aap.0000000000000841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Li N, Kong H, Li SL, Zhu SN, Wang DX. Combined epidural-general anesthesia was associated with lower risk of postoperative complications in patients undergoing open abdominal surgery for pheochromocytoma: A retrospective cohort study. PLoS One 2018; 13:e0192924. [PMID: 29466473 PMCID: PMC5821342 DOI: 10.1371/journal.pone.0192924] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 01/16/2018] [Indexed: 01/09/2023] Open
Abstract
Background Current evidences show that regional anesthesia is associated with decreased risk of complications after major surgery. However, the effects of combined regional-general anesthesia remain controversial. The purpose of our study was to analyze the impact of anesthesia (combined epidural-general anesthesia vs. general anesthesia) on the risk of postoperative complications in patients undergoing open surgery for pheochromocytoma. Methods This was a retrospective cohort study. 146 patients who underwent open surgery for pheochromocytoma (100 received combined epidural-general anesthesia and 46 received general anesthesia) in Peking University First Hospital from January 1, 2002 to December 31, 2015 were enrolled. The primary outcome was the occurrence of postoperative complications during hospital stay after surgery. Multivariate Logistic regression models were used to analyze the association between the choice of anesthetic method and the risk of postoperative complications. Results 17 (11.6%) patients developed complications during postoperative hospital stay. The incidence of postoperative complications was lower in patients with combined epidural-general anesthesia than in those with general anesthesia (6% [6/100] vs. 23.9% [11/46], P = 0.006). Multivariate Logistic regression analysis showed that use of combined epidural-general anesthesia (OR 0.219, 95% CI 0.065–0.741; P = 0.015) was associated with lower risk, whereas male gender (OR 5.213, 95% CI 1.283–21.177; P = 0.021) and perioperative blood transfusion (OR 25.879; 95% CI 3.130–213.961; P = 0.003) were associated with higher risk of postoperative complications. Conclusions For patients undergoing open surgery for pheochromocytoma, use of combined epidural-general anesthesia may decrease the occurrence of postoperative complications.
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Affiliation(s)
- Nan Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Hao Kong
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Shuang-Ling Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Sai-Nan Zhu
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
- * E-mail:
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Greimel F, Maderbacher G, Zeman F, Grifka J, Meissner W, Benditz A. No Clinical Difference Comparing General, Regional, and Combination Anesthesia in Hip Arthroplasty: A Multicenter Cohort-Study Regarding Perioperative Pain Management and Patient Satisfaction. J Arthroplasty 2017. [PMID: 28641966 DOI: 10.1016/j.arth.2017.05.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Steadily increasing numbers of hip arthroplasties are reported in the past years. Different types of anesthetic methods for surgery itself as well as pain management programs have been established. It is one of the main goals to reduce postoperative pain levels and guarantee better and faster mobilization in the postoperative period. The present study aims to compare the use of general and regional spinal anesthesia and their combination regarding perioperative pain management and patient satisfaction. METHODS All patients included in the present study had undergone primary hip arthroplasty. Parameters were analyzed on the first postoperative day within the scope of the "Quality Improvement in Postoperative Pain Management" project, which is conducted nationwide in 49 orthopedic departments at the time of data evaluation. RESULTS From 2009-2015, 18,118 patients underwent primary hip arthroplasty and have been evaluated. Demographic and general patient data were homogenous. The need for opioids was significantly higher in patients where general and combination anesthesia was applied (P < .001, respectively). Pain scores and pain management satisfaction were significantly better in regional and combination anesthesia (P < .001, respectively). CONCLUSION We were able to show a highly significant advantage in the use of regional or the combination of regional and general anesthesia in comparison with general anesthesia alone in hip arthroplasty regarding patients' satisfaction and the requirement of opioid pain medication, although maybe below clinical relevance.
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Affiliation(s)
- Felix Greimel
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Guenther Maderbacher
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center of Regensburg, Regensburg, Germany
| | - Joachim Grifka
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Winfried Meissner
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
| | - Achim Benditz
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
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Naqvi SY, Rabiei AH, Maltenfort MG, Restrepo C, Viscusi ER, Parvizi J, Rasouli MR. Perioperative Complications in Patients With Sleep Apnea Undergoing Total Joint Arthroplasty. J Arthroplasty 2017; 32:2680-2683. [PMID: 28583758 DOI: 10.1016/j.arth.2017.04.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/05/2017] [Accepted: 04/18/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study aims to evaluate the effect of sleep apnea (SA) on perioperative complications after total joint arthroplasty (TJA) and whether the type of anesthesia influences these complications. METHODS Using the ninth and tenth revisions of the International Classification of Diseases, coding systems, we queried our institutional TJA database from January 2005 to June 2016 to identify patients with SA who underwent TJA. These patients were matched in a 1:3 ratio based on age, gender, type of surgery, and comorbidities to patients who underwent TJA but were not coded for SA. Perioperative complications were identified using the same coding systems. Multivariate analysis was used to test if SA is an independent predictor of perioperative complications and if type of anesthesia can affect these complications. RESULTS A total of 1246 patients with SA were matched to 3738 patients without SA. Pulmonary complications occurred more frequently in patients with SA (1.7% vs 0.6%; P < .001), confirmed using multivariate analysis (odds ratio = 2.91; 95% confidence interval, 1.58-5.36; P = .001). Use of general anesthesia increased risk of all but central nervous system complications and mortality (odds ratio = 15.88; 95% confidence interval, 3.93-64.07; P < .001) regardless of SA status compared with regional anesthesia. Rates of pulmonary and gastrointestinal complications, acute anemia, and mortality were lower in SA patients when regional anesthesia was used (P < .05). CONCLUSION SA increases risk of postoperative pulmonary complications. The use of regional anesthesia may reduce risk of pulmonary complications and mortality in SA patients undergoing TJA.
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Affiliation(s)
- Syed Y Naqvi
- Department of Internal Medicine, Pennsylvania Hospital of the University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Amin H Rabiei
- Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mitchell G Maltenfort
- Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Camilo Restrepo
- Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Eugene R Viscusi
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mohammad R Rasouli
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania; Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Incidence and Risk Factors for Blood Transfusion in Total Joint Arthroplasty: Analysis of a Statewide Database. J Arthroplasty 2017; 32:2684-2687.e1. [PMID: 28579446 DOI: 10.1016/j.arth.2017.04.048] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/01/2017] [Accepted: 04/24/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Significant attempts have been made to adopt practices to minimize blood transfusion after total joint arthroplasty (TJA) because of transfusion cost and potential negative clinical consequences including allergic reactions, transfusion-related lung injuries, and immunomodulatory effects. We aimed to evaluate risk factors for blood transfusion in a large cohort of TJA patients. METHODS We used the all-payer California Healthcare Cost and Utilization Project data from 2006 to 2011 to examine the trends in utilization of blood transfusion among arthroplasty patients (n = 320,746). We performed descriptive analyses and multivariate logistic regression clustered by hospital, controlling for Deyo-Charlson comorbidity index, age, insurance type (Medicaid vs others), gender, procedure year, and race/ethnicity. RESULTS Eighteen percent (n = 59,038) of TJA patients underwent blood transfusion during their surgery, from 15% with single knee to 45% for bilateral hip arthroplasty. Multivariate analysis indicated that compared with the referent category of single knee arthroplasty, single hip had a significantly higher odds of blood transfusion (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.68-1.83), as did bilateral knee (OR, 3.57; 95% CI, 3.20-3.98) and bilateral hip arthroplasty (OR, 6.17; 95% CI, 4.85-7.85). Increasing age (eg, age ≥80 years; OR, 2.99; 95% CI, 2.82-3.17), Medicaid insurance (OR, 1.36; 95% CI, 1.27-1.45), higher comorbidity index (eg, score of ≥3; OR, 2.33; 95% CI, 2.22-2.45), and females (OR, 1.75; 95% CI, 1.70-1.80) all had significantly higher odds of blood transfusion after TJA. CONCLUSION Primary hip arthroplasties have significantly greater risk of transfusion than knee arthroplasties, and bilateral procedures have even greater risk, especially for hips. These factors should be considered when evaluating the risk for blood transfusions.
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Song JH, Park JW, Lee YK, Kim IS, Nho JH, Lee KJ, Park KK, Kim Y, Park JH, Han SB. Management of Blood Loss in Hip Arthroplasty: Korean Hip Society Current Consensus. Hip Pelvis 2017; 29:81-90. [PMID: 28611958 PMCID: PMC5465399 DOI: 10.5371/hp.2017.29.2.81] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/29/2017] [Accepted: 05/01/2017] [Indexed: 12/22/2022] Open
Abstract
The volume of hip arthroplasty is stiffly increasing because of excellent clinical outcomes, however it has not been shown to decrease the incidence of transfusions due to bleeding related to this surgery. This is an important consideration since there are concerns about the side effects and social costs of transfusions. First, anemia should be assessed at least 30 days before elective hip arthroplasty, and if the subject is diagnosed as having anemia, an additional examination of the cause of the anemia should be carried and steps taken to address the anemia. Available iron treatments for anemia take 7 to 10 days to facilitate erythropoiesis, and preoperative iron supplementation, either oral or intravenous, is recommended. When using oral supplements for iron storage, administer elemental iron 100 mg daily for 2 to 6 weeks before surgery, and calculate the dose using intravenous supplement. Tranexamic acid (TXA) is a synthetic derivative of the lysine component, which reduces blood loss by inhibiting fibrinolysis and clot degradation. TXA is known to be an effective agent for reducing postoperative bleeding and reducing the need for transfusions in primary and revision total hip arthroplasties. Patient blood management has improved the clinical outcome after hip arthroplasty through the introduction and research of various agents, thereby reducing the need for allogeneic blood transfusions and reducing the risk of transfusion-related infections and the duration of hospitalizations.
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Affiliation(s)
- Joo-Hyoun Song
- Department of Orthopaedics, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Jang Won Park
- Department of Orthopaedic Surgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In-Sung Kim
- Department of Orthopedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Jae-Hwi Nho
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital, Seoul, Korea
| | - Kyung-Jae Lee
- Department of Orthopaedic Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Kwan Kyu Park
- Department of Orthopaedic surgery, Yonsei University, College of Medicine, Seoul, Korea
| | - Yeesuk Kim
- Department of Orthopaedic Surgery, School of Medicine, Hanyang University, Seoul, Korea
| | - Jai Hyung Park
- Department of Orthopaedic surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Beom Han
- Department of Orthopedic Surgery, Korea University Anam Hospital, Seoul, Korea
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Esenyel AE, Esenyel CZ, Ervatan Z, Yakar N, Cakirgoz M, Kalkar I, Seyran M. Comparison of Anesthetic Administration According to Method of Hip Surgery. Eurasian J Med 2017; 49:26-29. [PMID: 28416928 DOI: 10.5152/eurasianjmed.2016.15281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 02/12/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of this study is to compare total hip prosthesis (THP), partial hip prosthesis (PHP), and proximal femoral nail (PFN) patients in terms of the chosen anesthetic method. METHODS A total of 850 patients who underwent hip surgery were divided into 3 groups according to the operation type: PHP (n=281), PFN (n=393), and THP (n=176). The type of anesthesia administered, interventions during anesthesia, and complications were retrospectively evaluated. The groups were compared in terms of patient age, American Society of Anesthesiologists (ASA) scores, chosen anesthetic method, operation duration, colloid use during operation, use of antihypertensive medication, use of vasoconstrictor medication, development of hypotension, blood transfusion administered, development of cardiac arrest, requirements for intensive care after operation, and use of a central catheter. RESULTS In the THP group, the mean age of patients was significantly lower as compared to the PHP and PFN groups. The duration of operation was lower in the PFN group as compared to the other two groups. In the THP group, general anesthesia was significantly high, while in the PFN group, regional anesthetic administration was high. While colloid use was greater in the PFN group, the blood transfusion rate was higher in the THP group. The use of antihypertensive medication was higher in the THP group as compared to the other groups. CONCLUSION Although all three anesthetic methods could be used in hip surgery, the type of anesthesia should be chosen according to the type of hip surgery considering the duration of operation, age of the patient, and blood lost during the operation.
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Affiliation(s)
- Aysin Ersoy Esenyel
- Clinic of Anaesthesiology and Intensive Care, Okmeydanı Training and Research Hospital, İstanbul, Turkey
| | - Cem Zeki Esenyel
- Clinic of Orthopaedic Surgery and Traumatology, Okmeydanı Training and Research Hospital, İstanbul, Turkey
| | - Zekeriya Ervatan
- Clinic of Anaesthesiology and Intensive Care, Okmeydanı Training and Research Hospital, İstanbul, Turkey
| | - Nuri Yakar
- Clinic of Anaesthesiology and Intensive Care, Okmeydanı Training and Research Hospital, İstanbul, Turkey
| | - Mensure Cakirgoz
- Clinic of Anaesthesiology and Intensive Care, Okmeydanı Training and Research Hospital, İstanbul, Turkey
| | - Ismail Kalkar
- Clinic of Orthopaedic Surgery and Traumatology, Okmeydanı Training and Research Hospital, İstanbul, Turkey
| | - Metin Seyran
- Clinic of Orthopaedic Surgery and Traumatology, Okmeydanı Training and Research Hospital, İstanbul, Turkey
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