Regional Anesthesia for Total Joints- Are you a Believer?

[BLADEMDA]

Unlike the AANA Anesthesiologists continue to do excellent clinical and laboratory research to advance the field.

Please look at the "basic case" below and ask if there is evidence to support the use of Regional Anesthesia over General.


Blade

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[BLADEMDA]

80 year old white male presents for THR. Patient can no longer ambulate without assistance due to severe left hip pain. Ortho dude has schedule a total hip replacement.

PMH:

1. HTN
2. Recent Memory troubles (Early dementia?)
3. Non-Insulin Dependent DM
4. DJD/Osteoarthritis
5. COPD- Quit at age 60

Meds:

1. Enalapril
2. Metformin
3. Ranitidine prn
4. Mobic
5. Lopressor


Vitals:

BP= 180/88 P=59 RR=14 Sat=95% RA T= 98.4 F

Labs: Hgb= 11.9 Plt= 187,000 Cr= 1.08 K= 4.2 EKG= SB 1AVB
CXR: No acute disease, mild cardiomegaly, COPD


Patient agrees to whatever "you think is best" for him.

 

[OB1🤙]

At our place we'd probably CSE this guy, low-dose prop to let him nap, neo/ephredrine prn concerning noggin perfusion pressures.

As to what advantage this has over GA- from a postop pain and mobility point of view it's superior, and maybe the incidence of thrombosis is lower with RA as well. I think it lends itself to a smoother anesthetic than GA, with less hemodynamic swings, but that's just a matter of style, not patient benefit necessarily.

I also prefer not to intubate elderly patients with COPD, though I don't think it matters very much unless you're talking about outrageous disease.

 

[Planktonmd]

Honestly (Sorry Blade) I don't think we have strong evidence suggesting that regional anesthesia is better than General anesthesia in any setting.
I know that there was recent data suggesting that regional would decrease the risk of surgical site infection ( which I think made Blade post this thread) but I truly believe that a properly done GA combined with a solid post-op plan to manage pain is as good as regional anesthesia.

 

[BLADEMDA]

Abstract:

Background: Epidural or spinal anesthesia involves several mechanisms hypothesized to reduce risk of surgical site infections (SSIs) during this decisive period. This study aims to compare the risk of SSI within 30 days of surgery for patients receiving total hip or knee replacement under general anesthesia versus those under epidural or spinal anesthesia.
Methods: We used the Longitudinal Health Insurance Database of Taiwan. A total of 3,081 patients who underwent primary total hip or knee replacement from 2002 to 2006 were included in the study. Multivariate logistic regression and propensity score analyses were carried out to explore the relationship between method of surgical anesthesia and SSI occurring within 30 days of surgery.
Results: Of the 3,081 sampled patients, 56 patients (1.8%) had 30-day SSIs; 33 (2.8% of all under general anesthesia) of them had general anesthesia, and 23 (1.2% of all under epidural or spinal anesthesia) had epidural or spinal anesthesia (P = 0.002). The odds of SSI for patients receiving total hip or knee replacement under general anesthesia were 2.21 (95% CI = 1.25-3.90, P = 0.007) times higher than those who had the same procedure under epidural or spinal anesthesia, after adjusting for the patient's age, sex, the year of surgery, comorbidities, surgeon's age, and hospital teaching status.
Conclusions: Total hip or knee replacement under general anesthesia is associated with higher risk of SSI compared with epidural or spinal anesthesia. Our results support the evolving concept of long-term consequences of anesthesia and emphasize the anesthesiologist's role in preventing SSIs.
(C) 2010 American Society of Anesthesiologists, Inc.

 

[Vie221]

Regional does have the benefit of preventing wind up and activation of nmda receptors. This would theoretically reduce future chronic pain issues. However, given this guy's age, it might not be too much of a consideration here.

 

[Planktonmd]

abstract:

background: Epidural or spinal anesthesia involves several mechanisms hypothesized to reduce risk of surgical site infections (ssis) during this decisive period. This study aims to compare the risk of ssi within 30 days of surgery for patients receiving total hip or knee replacement under general anesthesia versus those under epidural or spinal anesthesia.
Methods: We used the longitudinal health insurance database of taiwan. A total of 3,081 patients who underwent primary total hip or knee replacement from 2002 to 2006 were included in the study. Multivariate logistic regression and propensity score analyses were carried out to explore the relationship between method of surgical anesthesia and ssi occurring within 30 days of surgery.
Results: Of the 3,081 sampled patients, 56 patients (1.8%) had 30-day ssis; 33 (2.8% of all under general anesthesia) of them had general anesthesia, and 23 (1.2% of all under epidural or spinal anesthesia) had epidural or spinal anesthesia (p = 0.002). The odds of ssi for patients receiving total hip or knee replacement under general anesthesia were 2.21 (95% ci = 1.25-3.90, p = 0.007) times higher than those who had the same procedure under epidural or spinal anesthesia, after adjusting for the patient's age, sex, the year of surgery, comorbidities, surgeon's age, and hospital teaching status.
Conclusions: total hip or knee replacement under general anesthesia is associated with higher risk of ssi compared with epidural or spinal anesthesia. Our results support the evolving concept of long-term consequences of anesthesia and emphasize the anesthesiologist's role in preventing ssis.
(c) 2010 american society of anesthesiologists, inc.

 

[BLADEMDA]

CONCLUSION: The use of light propofol sedation decreased the prevalence of postoperative delirium by 50% compared with deep sedation. Limiting depth of sedation during spinal anesthesia is a simple, safe, and cost-effective intervention for preventing postoperative delirium in elderly patients that could be widely and readily adopted.


http://www.mayoclinicproceedings.com/content/85/1/18.abstract

 

[BLADEMDA]

Honestly (Sorry Blade) I don't think we have strong evidence suggesting that regional anesthesia is better than General anesthesia in any setting.
I know that there was recent data suggesting that regional would decrease the risk of surgical site infection ( which I think made Blade post this thread) but I truly believe that a properly done GA combined with a solid post-op plan to manage pain is as good as regional anesthesia.

Plankton,

I agree with you. But, there is some evidence now that patients with dementia/early dementia undergoing a total joint replacement may benefit from Neuraxial or Regional Anesthesia with light sedation.

In no way am I implying that Regional is the gold standard in these opeartions. I am just pointing out the possibility of potential benefits.

 

[BLADEMDA]

Influence of Anesthesia
on the Rate of Thrombosis
It is well documented in the literature that, when patients are
not treated with any prophylaxis after total hip arthroplasty,
those who have received spinal or epidural anesthesia have a
decreased rate of thrombosis compared with those who have​

received general anesthesia

23,74,107-109. It has been hypothesized

that the decrease in the formation of thrombi associated with
regional anesthesia is due to the sympathetic blockade, with
subsequent vasodilation and an increased blood flow to the
lower extremities​

​

16. Total hip arthroplasty generally results in a

hypercoagulable state secondary to systemic activation of the
coagulation cascade (Fig. 2). Blood loss has been reported to
be decreased with the use of epidural anesthesia alone or in
combination with general anesthesia as compared with general​

anesthesia alone110.


http://www.mc.vanderbilt.edu/medschool/organizations/oig/documents/prevention%20of%20dvt-pe%20after%20total%20joints.pdf


​

 

[BLADEMDA]

Many reports over the past two decades have attempted to compare risks and benefits of regional and general anesthesia in different patient populations. Rodgers et al. (1) performed a meta-analysis on studies comparing neuraxial versus general anesthesia with regard to post-operative mortality and morbidity. These authors concluded that neuraxial blockade reduces major post-operative complications in a wide variety of surgical patients, with the greatest reductions seen in the orthopedic population. These complications included deep venous thrombosis, pulmonary embolism, blood transfusion requirements, pneumonia, and respiratory depression.
In a retrospective review of in-hospital morbidity and mortality at HSS, Sharrock et al. (2) reported a decrease in mortality rate from 0.36% (13 of 3622 patients) during the period of 1981 to 1985, to 0.01% (6 of 5869 patients) during the period of 1987 to 1991.


Considering the evidenced-based risks and benefits of regional anesthesia for TKR, as well as our extensive clinical experience, anesthesiologists at HSS firmly believe that the neuraxial anesthetics are superior techniques.


http://www.hss.edu/professional-conditions_28469.asp

 

[BLADEMDA]

In conclusion, the anesthetic and analgesic management of patients during and following TKR and THR may have a significant impact on medical and surgical outcome, as well as patient satisfaction. The anesthetic experience at HSS over the past two decades has included thousands of TKR and THR procedures. It is important to continually adapt and improve anesthetic and analgesic techniques to ensure the highest quality in medical care, minimize side effects and complications, and maintain a high degree of efficiency and patient satisfaction. In considering all of the evidence, anesthesiologists at HSS overwhelmingly agree that neuraxial anesthesia supplemented by analgesic nerve and plexus blocks have both real and potential advantages over general anesthesia and intravenous narcotics for TKR and THR.

Posted: 1/18/2010

 

[epidural man]

Influence of Anesthesia​

on the Rate of Thrombosis
​

​

​

​

​

​

It is well documented in the literature that, when patients are
not treated with any prophylaxis after total hip arthroplasty,
those who have received spinal or epidural anesthesia have a
decreased rate of thrombosis compared with those who have​

received general anesthesia

​

​

23,74,107-109. It has been hypothesized​

that the decrease in the formation of thrombi associated with

regional anesthesia is due to the sympathetic blockade, with
subsequent vasodilation and an increased blood flow to the
lower extremities​

​

​

​

​

16. Total hip arthroplasty generally results in a​

hypercoagulable state secondary to systemic activation of the

coagulation cascade (Fig. 2). Blood loss has been reported to
be decreased with the use of epidural anesthesia alone or in
combination with general anesthesia as compared with general​

​

​

anesthesia alone

110.

http://www.mc.vanderbilt.edu/medsch...s/prevention of dvt-pe after total joints.pdf​

​

I think most studies that showed a decrease in DVT/PE with regional techniques were before potent anticoagulants were instituted.

However, interestingly enough, no one ever talks about this article for some reason. Should we not be using more epidurals and for longer duration maybe?

Potent Anticoagulants are Associated with a Higher All-Cause Mortality Rate After Hip and Knee Arthroplasty
http://www.springerlink.com/content/vxr454h43620g8u3/

​

 

[jennyboo]

When the surgeon is predictable and does a fast enough primary hip, I've done these as either:

- spinal +/- femoral or combined femoral-sciatic single shot blocks, or
- GA +/- femoral or combined femoral-sciatic single shot blocks.

No peripheral nerve catheters because it's just not done (yet) in this hospital.

Regardless of whether the patient gets peripheral nerve block or a PCA after the procedure, the patients are quickly given Coumadin (hence no post-op epidural) and are mobilized out of bed on POD #1. Surgeon seems happy with the nerve blocks, else he wouldn't be requesting them for all of his patients.

For me the jury's still out; I'll need to follow up a lot more of these patients to decide for myself how much the fem/sciatic blocks help.

 

[Planktonmd]

There is no right answer!
And like everything else in this field, there is no absolute right or absolute wrong.
Each patient is different and each anesthesiologist is different, so what works for a certain patient in the hands of a certain anesthesiologist might not work for another patient or in the hands of a different anesthesiologist.
At the end of the day, a good general anesthetic (if you know how to do it) is never the wrong answer.

 

[sevo85288]

You do fem n blocks for hips? Do you mean TKA?

When the surgeon is predictable and does a fast enough primary hip, I've done these as either:

- spinal +/- femoral or combined femoral-sciatic single shot blocks, or
- GA +/- femoral or combined femoral-sciatic single shot blocks.

No peripheral nerve catheters because it's just not done (yet) in this hospital.

Regardless of whether the patient gets peripheral nerve block or a PCA after the procedure, the patients are quickly given Coumadin (hence no post-op epidural) and are mobilized out of bed on POD #1. Surgeon seems happy with the nerve blocks, else he wouldn't be requesting them for all of his patients.

For me the jury's still out; I'll need to follow up a lot more of these patients to decide for myself how much the fem/sciatic blocks help.

 

[Mman]

You do fem n blocks for hips? Do you mean TKA?

You could do a single shot fascia iliaca block for a hip, but blocking the femoral nerve itself wouldn't do anything for postop pain.

 

[sevoflurane]

I think the below pictures are the most useful pictures of the lower extremity in relation to regional anesthesia (particularly the osteotome pictures).

Lumbar Plexus (T12-L5 (high up at the root level)
Femoral L2,3,4. L4 forms the femoral nerve but it’s contribution to the sciatic is long gone when you do a femoral or fascia iliaca. It’s this reason that the femoral nerve is not a good block for hip surgery.

Fascia Iliaca is better but it’s coverage is incomplete. However, it is such an easy block to do that it’s worth doing and patients do get analgesia from it. Blocking the lateral femoral can also cover incisional pain associated with hip surgery.

Hip Joint:
L2,3,4 (at the level of the plexus- not post plexus like femoral nerve ),5,S1

I like to do Lumbar Plexus/ High Parasacral Sciatic. IMHO, it’s the best approach (not including spinals) to hips and you can prep both at the same time.

I always like getting peroneal or tibial when doing a LP... with enough volume, you potentially can get all the hip with one shot. It just makes me happy when i see the foot everting when doing a LP.

http://www.youtube.com/watch?v=FFLmfyr-sqg

 

[sevoflurane]

BTW, the osteotome picture shows you why you get posterior knee pain with TKA. You are completely missing L5 and S1 (sciatic)

 

[Planktonmd]

A good fascia iliaca block is almost always effective for hip arthroplasy and it is very easy to perform and has almost zero complications.
The trick is to use high volume (40-50 cc).
On the other hand if your surgeon is doing anterior approach hip surgery then the fascia iliaca block does not seem to work very well, possibly because your local anesthetic will be removed once they enter the fascia.

 

[sevoflurane]

A good fascia iliaca block is almost always effective for hip arthroplasy and it is very easy to perform and has almost zero complications.
The trick is to use high volume (40-50 cc).
On the other hand if your surgeon is doing anterior approach hip surgery then the fascia iliaca block does not seem to work very well, possibly because your local anesthetic will be removed once they enter the fascia.

The good thing that it's less painful since there is not a lot of muscle trauma/detachment of muscle from pelvis/femur. It's also advantageous in that it has a much lower risk of dislocation compared to the posterior approach.

I'd want an anterior approach 😀

 

[epidural man]

You do fem n blocks for hips? Do you mean TKA?

Place a stimulating catheter - and you can steer the catheter up the nerve some centimeters to make sure you get the hip fibers.

 

[epidural man]

The good thing that it's less painful since there is not a lot of muscle trauma/detachment of muscle from pelvis/femur. It's also advantageous in that it has a much lower risk of dislocation compared to the posterior approach.

I'd want an anterior approach 😀

i just noticed your pic. cool! where you at (beside 5 ft in the air?)

 

[sevoflurane]

Summit County CO. My old stomping grounds. I think that was taken at A-Basin.
As of recently I've become more of a fan of southern colorado.
Kinda of a hidden gem.
Real old school/western towns with tons of snow and great terrain.

Purgatory, Silverton mountain (big f'n thumbs up, but not for the faint of heart), Telluride, Wolf Creek.

Telluride and it's surrounding mountains is prolly one of the most beautiful areas in the US, IMHO.
Breath taking.....

 

[onlyatest]

Many reports over the past two decades have attempted to compare risks and benefits of regional and general anesthesia in different patient populations. Rodgers et al. (1) performed a meta-analysis on studies comparing neuraxial versus general anesthesia with regard to post-operative mortality and morbidity. These authors concluded that neuraxial blockade reduces major post-operative complications in a wide variety of surgical patients, with the greatest reductions seen in the orthopedic population. These complications included deep venous thrombosis, pulmonary embolism, blood transfusion requirements, pneumonia, and respiratory depression.
In a retrospective review of in-hospital morbidity and mortality at HSS, Sharrock et al. (2) reported a decrease in mortality rate from 0.36% (13 of 3622 patients) during the period of 1981 to 1985, to 0.01% (6 of 5869 patients) during the period of 1987 to 1991.


Considering the evidenced-based risks and benefits of regional anesthesia for TKR, as well as our extensive clinical experience, anesthesiologists at HSS firmly believe that the neuraxial anesthetics are superior techniques.


http://www.hss.edu/professional-conditions_28469.asp

The way Sharrock does his total hips may not be what everybody here is thinking when they hear "epidural for THR." He injects enough local anesthetic through the Tuohy needle to induce a profound sympathetectomy (not divided doses the way most of you probably do). He then uses an epinephrine infusion to control heart rate/blood pressure. This creates a high cardiac output, low systemic vascular resistance condition. I worked with one regional fellow who told me many of the attendings at HSS would titrate MAPS to the 50's using this technique to limit blood loss, Sharrock would sometimes titrate to even lower BPs.

It is my personal belief that the HSS studies for regional anesthesia should be understood in the context that the way they do things is probably not going to be the way you do things (or the way your surgeons would let you do things), so the results may not be comparable.

Also, when using an epidural catheter, I believe they give the first dose of warfarin on the evening of POD #0, and then pull the epidural catheter on the morning of POD #1. I know the HSS website says they follow the ASRA guidelines, and I understand pharmacokinetically why this is probably (almost always) okay, but this just doesn't sound like an awesome idea to me (I would just give the first dose 12hours later - no big deal right?).

___________________

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