Postoperative Outcomes Associated With Neuraxial vs General Anesthesia Following Bilateral Total Knee Arthroplasty

doi:10.1016/j.arth.2017.06.028

The Journal of Arthroplasty

Volume 32, Issue 12, December 2017, Pages 3632-3636

https://doi.org/10.1016/j.arth.2017.06.028 Get rights and content

Abstract

Background

There is sparse evidence on the benefit of neuraxial (NA) vs general anesthesia (GA) as the primary anesthetic in postoperative outcomes following bilateral total knee arthroplasty. We sought to elucidate differences in outcomes in this surgical population using a national database.

Methods

We used data from the National Surgical Quality Improvement Program from 2007 to 2013 and compared rates of various postoperative outcomes in propensity-matched cohorts (NA vs GA).

Results

After exclusion, there were 1957 patients included in the final analysis, of which 26% received NA as the primary anesthetic. Propensity-matched cohorts were generated to ensure no differences in various comorbidities (including bleeding disorders or inadequate cessation of anticoagulation therapy), case duration, and patient demographics between both cohorts. Among the matched cohorts, there were no differences in preoperative platelet count, hematocrit, or international normalized ratio. NA was associated with decreased blood transfusion requirement and decreased total number of units of blood products transfused (P < .0001 for both outcomes). However, there were no differences in other outcomes, including hospital length of stay, pulmonary embolism, deep vein thrombosis, or urinary tract infections.

Conclusion

Our study demonstrates that in matched cohorts, NA is associated with decreased blood transfusion requirements in patients undergoing bilateral total knee arthroplasty when compared to GA as the primary anesthetic.

Section snippets

Data Collection

Data were obtained from the publicly available dataset, American College of Surgeons NSQIP for the years 2007-2013. This is a multicenter, prospective, outcome-oriented database. Because the database is de-identified, it meets the criteria of the Health Insurance Portability and Accountability Act to protect personal information and was exempt from the consent requirement by our institutional review board. This database contains data from >200 participating hospitals for patients who underwent

Results

There were a total of 2,820,370 cases in NSQIP, of which 81,679 underwent a TKA. From these, a total of 2078 underwent BTKAs during the same surgical encounter. After exclusion, there were 1957 patients included in the final analysis (119 of the original total were removed due to lack of information regarding primary anesthesia type). Table 1 outlines the demographics in both cohorts. Cases performed under GA tended to be longer than those performed under an NA technique (median of 148 vs

Discussion

Using a large national database and including 1957 patients who received BTKA, this study demonstrated that NA was associated with less blood product transfusions and less total number of blood products transfused as compared to GA. Furthermore, there was no difference in preoperative INR, platelet count, hematocrit, or bleeding disorders in both cohorts. However, choice of anesthetic technique had no statistically significant impact on hospital length of stay, deep vein thrombosis, or

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Cited by (16)

Does spinal anesthesia for total hip or knee arthroplasty entail longer operating room occupancy compared to general anesthesia? Case-control study of 337 spinal versus 243 general anesthesias
2024, Orthopaedics and Traumatology: Surgery and Research
Treatment protocols, including anesthesia, are constantly progressing to improve rapid early postoperative recovery in lower-limb arthroplasty. To the best of our knowledge, however, no studies compared general versus spinal anesthesia (GA vs. SA) in the surgical pathway of patients undergoing total knee or hip arthroplasty (TKA, THA). Better knowledge of the processes should improve efficacy in theater and optimize surgical planning. The present study comparing GA and SA in the operating room aimed to assess (1) theater occupancy times, and (2) times for each step in a surgery day according to type of anesthesia.
SA leads to longer theater occupancy than GA in TKA and THA.
A single-center retrospective case-control study analyzed data for the period January 2019 to December 2020 in 303 TKAs (100 GA, 203 SA) and 277 THAs (143 GA, 134 SA), comparing times for all perioperative steps and particularly theater occupancy.
In TKA, occupancy did not differ between GA and SA: 98 ± 16 min versus 98 ± 14 min respectively; Δ = 0 min (p = 0.78). In THA, occupancy was shorter with SA than GA: 117 ± 23 min versus 123 ± 26 min respectively; Δ = −6 min (p = 0.02). In THA, time to perform SA was longer than induction of GA: 28 ± 13 min versus 23 ± 12 min respectively; Δ = +5 min (p < 0.001). In TKA, time to leaving the operating room was shorter with SA than GA: 8 ± 5 min versus 14 ± 7 min respectively; Δ = −6 min (p < 0.001).
SA did not involve longer mean theater occupancy than GA for TKA, and reduced it by 6 minutes for THA.
III; case-control study.
Modern Lower Extremity Bypass Outcomes by Anesthesia Type in the Veteran Population
2022, Annals of Vascular Surgery
Citation Excerpt :
Higher rates of pneumonia and pulmonary complications seen in the GA group are likely related to intubation and ventilator use. The higher transfusion requirement in general anesthesia as opposed to NA is seen in several studies 6,7,8,23,24 and again replicated in our study. The patients who underwent NA had lower rates of bleeding disorders at baseline which likely represents a concern for epidural hematoma, a known complication of NA use.
Lower extremity bypass (LEB) revascularization can be performed under general (GA) or neuraxial anesthesia (NA). Studies show that the use of NA may decrease morbidity, 30-day mortality, and hospital length-of-stay (LOS). The goal of our analysis is to examine the differences in postsurgical outcomes following LEB between patients who undergo GA compared to NA in the Veteran Affairs Surgical Quality Improvement Program (VASQIP) database.
After IRB approval, the VASQIP database was assessed for patients who underwent LEB between 1998–2018. Only infrainguinal bypass procedures and anesthesia type classified as “general,” “epidural,” or “spinal” were included. The neuraxial cohort includes both spinal and epidural anesthesia patients. The Risk Analysis Index (RAI), a validated measure of frailty, was additionally calculated for each patient. Chi squared, paired t-test, and binary logistic regression were used to compare the cohorts.
During this period, 22,960 veterans underwent LEB recorded in VASQIP. Compared to those who underwent surgery under GA, patients with procedures performed using NA were older (66.4 ± 9.6 years vs. 65.3 ± 9 years respectively; P <0.001) and more frail (average RAI score 25.7 ± 7.0 vs. 24.9 ± 6.7; P < 0.001). Operative time was shorter in the NA group (4.1 ± 1.7 hrs vs. 4.7 ± 3.0 hrs; P < 0.001) and fewer cases were emergent (1.55% vs. 4.13%; P <0.001). Patients in the GA group had higher rates of postoperative prolonged ileus (0.31% vs. 0.00%; P = 0.03), pneumonia (1.60% vs. 1.06%; P = 0.025), deep wound infection (2.67% vs. 2.61%; P = 0.01), sepsis (1.68% vs. 0.79%; P < 0.001), reintubation (1.80% vs. 1.30%) (P = 0.04),and number of packed red blood cell (pRBC) transfused intraoperatively (0.39 ± 1.21 units vs. 0.22 ± 0.79 units; P <0.001). There was no significant difference in rate of graft failure, return to the OR, myocardial infarction, death, or LOS. In regression analysis, those undergoing NA were less likely to require pRBC transfusion intraoperatively (OR: 0.43; 95% CI: 0.31–0.61; P < 0.001), however no other outcomes reached statistical significance.
Although younger and less frail, veteran patients undergoing GA for lower extremity revascularization had higher rates of postoperative ileus, pneumonia, deep wound infection, sepsis, and need for transfusion as compared to those undergoing NA. There was no significant difference in the rate of other major complications, myocardial infarction, death or LOS. After adjustment, only intraoperative transfusion remained statistically significant, likely reflecting longer and more complex cases for those that undergo general anesthesia rather than the effect of anesthetic choice itself.
Lower Dosing of Bupivacaine Spinal Anesthesia Is Not Associated With Improved Perioperative Outcomes After Total Joint Arthroplasty
2021, Arthroplasty Today
Citation Excerpt :
In addition, SA is preferred at some institutions over GA because of its low cost, reliability, rapid onset, and ideal duration of action for arthroscopy and arthroplasty. These findings suggest that SA not only provides a functional benefit to patients perioperatively but may also serve to preserve health-care resources and minimize unnecessary expenses [10-12]. Over the last few decades, fast-track protocols have been introduced for TJA to reduce hospital LOS without a concurrent increase in complications or readmissions [13].
The choice of anesthesia plays a significant role in the success of total joint arthroplasty (TJA). Isobaric bupivacaine spinal anesthesia is often used. However, dosing of bupivacaine has not been extensively studied and is usually at the discretion of the treating anesthesiologist and surgeon. The goal of this study was to determine what, if any, effect the dose of bupivacaine spinal anesthesia had on perioperative outcomes in TJA.
A total of 761 TJAs performed with bupivacaine spinal anesthesia by arthroplasty surgeons were retrospectively reviewed. Perioperative outcomes evaluated were operation duration, estimated blood loss, length of stay (LOS) in the postanesthesia care unit, hospital LOS, discharge disposition, episodes of intraoperative hypotension, postoperative nausea and vomiting, and missed physical therapy sessions because of postoperative symptoms of hypotension. A Student’s t-test was used for continuous variables, and a chi-squared test was used for categorical variables.
Of the 761 patients, 499 (65.6%) received 15 mg isobaric bupivacaine while 262 (34.4%) received <15 mg (range = 7.5-14.5 mg, median = 12.5 mg). With the numbers available in this cohort, lower doses of bupivacaine were not associated with any significant differences between groups for any of the studied perioperative outcomes, including proportion of patients discharged home or LOS.
Dosage of bupivacaine spinal anesthetic did not affect perioperative outcomes. Bupivacaine may not have a dose-related response curve in this regard, and if seeking to perform same-day or outpatient TJA, other agents may need to be considered, rather than smaller doses of bupivacaine.
Impact of body mass index on hemoglobin level and blood transfusion in total knee arthroplasty: A retrospective case control study
2020, Annals of Medicine and Surgery
Citation Excerpt :
Our study demonstrated that estimated blood loss was less among patients with Neuraxial (NA) vs general anesthesia (GA). Walker et al. studied postoperative outcomes associated with NA vs GA following bilateral total knee arthroplasty and showed the same result [30]. The mechanism of reduced requirement of blood transfusions in the setting of NA is unclear.
Morbid obesity is a challenge in cases that require total knee arthroplasty, and several studies considered it a contraindication for the procedure due to associated risk of complications, including plummeting hemoglobin levels and subsequent need for a blood transfusion. This study investigated risk factors for blood transfusion in this patient group and considered their relationship to obesity.
Patients’ data were extracted from medical records, including estimated blood loss and perioperative hemoglobin levels. Patients were weighed and measured, and their body mass index (BMI) was calculated and stratified according to international criteria.
A total of 188 patients were included in this study; among them, 136 patients had obesity (72%), with a mean BMI of 33.54. The mean volume of blood lost was 1055.4 ml, with the mean postoperative hemoglobin decrease of 1.42 g/dl and 2.88 g/dl at 6 and 24 h after surgery, respectively. The pre-operative Hb level was the only significant risk factor for blood transfusion. BMI did not affect the risk of blood transfusion or amount of blood lost.
Obesity (BMI > 30 kg/m²) did not increase the risk of needing a blood transfusion after total knee arthroplasty. A judicious transfusion strategy involving the pre-operative Hb optimization should be adopted in TKA to decrease transfusion rate, benefit patient outcomes, and increase healthcare system efficiency. This study shows that high BMI is not a risk factor for postoperative blood transfusion.
Obesity does not increase blood loss or incidence of immediate postoperative complications during simultaneous total knee arthroplasty: A multicenter study
2020, Knee
Citation Excerpt :
Previous studies have reported the use of drain increase the transfusion and infection rate and no drain use is safe and acceptable in the setting of primary TKA [30,31]. Third, Walker et al. demonstrated that neuraxial anesthesia was associated with decreased blood transfusion requirements in patients undergoing SBTKA compared with general anesthesia [32]. In addition, Feng et al. found that general anesthesia was associated with a higher risk of cardiac complications [33].
The purpose of the study was to determine blood loss, transfusion risk, and incidence of immediate postoperative complications in normal, overweight, and I–II obese patients undergoing simultaneous bilateral total knee arthroplasty (SBTKA).
We identified 1070 SBTKA procedures, and separated the patients into three groups on the basis of body mass index (BMI), including normal (BMI: 18.0–24.9 kg/m²), overweight (BMI: 25.0–29.9 kg/m²), and obese groups (BMI: ≥ 30.0 kg/m²). The primary outcome was total blood loss and secondary outcomes were dominant and hidden blood loss, transfusion rate and volume, hemoglobin (Hb) and hematocrit drop and other complications.
Patient's blood volume increased gradually among normal, overweight, and obese groups. There was no significant difference in blood loss or incidence of complications among the three groups, while the transfusion rate in the normal group was higher than that in overweight (36.0% vs 27.6%, p = 0.007) and obese groups (36.0% vs 24.6%, p = 0.006). In addition, the independent risk factors for complications among all groups following SBTKA included lower level of preoperative Hb (p = 0.040), general anesthesia (p = 0.002), drain use (p = 0.005), and transfusion (p < 0.001).
I–II obesity does not increase patient's blood loss, transfusion risk, or immediate postoperative complications following SBTKA. Obese and overweight patients may have lower transfusion needs compared with normal patients because of their higher basal blood volume. The risk factors for complications after SBTKA are lower level of preoperative Hb, general anesthesia, drain use and transfusion.
General vs Spinal Anesthesia for Total Joint Arthroplasty: A Single-Institution Observational Review
2020, Journal of Arthroplasty
Total joint arthroplasty (TJA) can be successfully carried out under general (GA) or spinal anesthesia (SA). The existing literature does not adequately illustrate which technique is optimal. The purpose of this study is to prospectively compare the effects of anesthesia technique on TJA outcomes.
This 2-year, prospective, observational study was conducted at a single institution where patients receiving primary TJA were consecutively enrolled. Patients were contacted postoperatively to assess for any 90-day complications. The primary outcome of the study was the overall complication rate.
A total of 2242 patients underwent total hip arthroplasty (n = 656; 29.26%) or total knee arthroplasty (n = 1586; 70.74%) between 2015 and 2017. Of these procedures, 1325 (59.10%) were carried out under SA and 917 (40.90%) were carried out under GA. Patients in the GA cohort had higher mean Charlson Comorbidity Index scores (0.05 SA vs 0.09 GA; P < .05) and higher average body mass index (29.35 SA vs 30.24 GA; P < .05). On multivariate analysis, patients in the SA cohort had a significantly lower overall complication rate relative to their GA counterparts (7.02% vs 10.14%; odds ratio, 0.66; 95% confidence interval, 0.49-0.90; P < .05). In addition, length of stay in the GA cohort was significantly longer (2.43 [SD, 1.62] vs 2.18 [SD, 0.88] days; P < .01) and a larger percentage of GA patients were discharged to a nursing facility (32.28% vs 25.06%; odds ratio, 0.55; 95% confidence interval, 0.44-0.70; P < .05).
Our study demonstrates that SA for TJA is associated with a decrease in overall complications and healthcare resource utilization.

View all citing articles on Scopus

: Author contributions: Jeffrey B. Walker, Patrick L. Nguyen, Ulrich H. Schmidt, and Rodney A. Gabriel helped design the study, conduct the study, and prepare the manuscript. Rodney A. Gabriel collected the data; Jeffrey B. Walker and Rodney A. Gabriel analyzed the data.

: Funding support from National Library of Medicine (NLM) training grant number T15LM011271.

: No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.06.028.

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Primary ArthroplastyPostoperative Outcomes Associated With Neuraxial vs General Anesthesia Following Bilateral Total Knee Arthroplasty

Abstract

Background

Methods

Results

Conclusion

Section snippets

Data Collection

Results

Discussion

Lancet

Br J Anaesth

J Arthroplasty

J Arthroplasty

Most Frequent Operating Room Procedures Performed in U.S. Hospitals, 2003-2012: Statistical Brief #186, in Healthcare Cost and Utilization Project (HCUP) Statistical Briefs

Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010

JAMA

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

J Bone Joint Surg Am

Anesthesia technique and mortality after total hip or knee arthroplasty: a retrospective, propensity score-matched cohort study

Anesthesiology

Neuraxial anesthesia decreases postoperative systemic infection risk compared with general anesthesia in knee arthroplasty

Anesth Analg

The impact of neuraxial versus general anesthesia on the incidence of postoperative surgical site infections following knee or hip arthroplasty: a meta-analysis

Reg Anesth Pain Med

Perioperative comparative effectiveness of anesthetic technique in orthopedic patients

Anesthesiology

Primary Arthroplasty
Postoperative Outcomes Associated With Neuraxial vs General Anesthesia Following Bilateral Total Knee Arthroplasty