Recovery After Total Intravenous General Anaesthesia or Spinal Anaesthesia for Total Knee Arthroplasty

Harsten, Andreas; Kehlet, Henrik

doi:10.1097/01.sa.0000441020.85061.85

Cited by 24 publications

(52 citation statements)

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“…4,12 Although there is a lack of studies directly comparing the effect of the anesthesia technique on OI or OH as a primary outcome, two studies with 120 THA and 120 total knee arthroplasty (TKA) patients compared GA using total intravenous anesthesia vs spinal anesthesia. The study results showed that more patients in the GA group were able to walk five metres six hours after surgery and that fewer patients in the GA group reported dizziness (i.e., symptomatic OH) 13,14 despite similar or slightly lower use of patient-controlled analgesia (PCA) opioids in the spinal group. Nevertheless, the use of larger doses of opioids may potentially cause OH as they have vagotonic effects and have been shown to dampen efferent baroreflex activity.…”

Section: Patient-related Factorsmentioning

confidence: 88%

Postoperative orthostatic intolerance: a common perioperative problem with few available solutions

Jans

Kehlet

2016

Can J Anesth/J Can Anesth

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Over the past decade or so, several procedure-specific Enhanced Recovery After Surgery (ERAS) programs have been documented to have beneficial effects, including reduced length of stay (and fewer medical complications) without increasing hospital readmission rates. Early mobilization has been a key element in the multimodal concept of fast-track surgery and ERAS programs, with subsequent positive effects on pulmonary and thromboembolic complications and avoidance of loss of muscle function through immobility. Although postoperative orthostatic intolerance (OI), characterized by symptoms of dizziness, nausea, vomiting, blurred vision, or syncope during sitting or standing, 1 is a well-known clinical problem that can delay early mobilization, relatively few data are available on its mechanism and possible treatment. Consequently, the aim of this freestanding editorial is to provide an update and perspective on the current knowledge regarding the pathogenesis and mechanisms of OI and potential future treatment strategies. Prevalence and mechanismsAlthough reports have indicated that OI was not a problem after relatively minor surgery (e.g., mastectomy), 2 prospective studies of major surgery have reported that OI is a common problem during early postoperative mobilization, with a prevalence of 42-50%. 3,4Retrospective studies with less well-defined mobilization protocols have reported an OI prevalence in the range of 12-60% across surgical procedures. 5-7The few existing studies with detailed recordings of hemodynamic changes during early postoperative mobilization and with a preoperative control-i.e., in prostatectomy and total hip arthroplasty (THA)-suggest that orthostatic hypotension (OH) with a concomitant decrease in cerebral perfusion is the main mechanism for the OI symptoms experienced in most cases. 3,4,8 Furthermore, the results from these studies suggest that OH is caused by a postoperative attenuated postural vasopressor response during early mobilization. Thus, in both prostatectomy and THA patients, the normal increase in total peripheral resistance during postural change was impaired compared with a preoperative evaluation.3,4 In a separate study in 42 prostatectomy patients, norepinephrine concentrations were measured during early mobilization, and the increase in norepinephrine during transition from supine to standing was impaired during early postoperative mobilization in OI patients. This suggests an attenuated vasopressor response compared with preoperative levels. Finally, a secondary analysis of heart rate variability between pre-and early postoperative mobilization in 23 THA patients found autonomic dysregulation during early mobilization. When compared with the preoperative evaluation, there was a paradoxical shift towards increased vagal activity with movement from the supine to the standing position in OI patients six and 24 hr postoperatively.9 Thus, a state of impaired cardiovascular regulation and autonomic dysfunction may be present in the early postoperative period with undesirable ...

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Section: Patient-related Factorsmentioning

confidence: 88%

Postoperative orthostatic intolerance: a common perioperative problem with few available solutions

Jans

Kehlet

2016

Can J Anesth/J Can Anesth

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“…These could then be evaluated in randomised controlled trials that use contemporaneous outcomes (see above) and control for casemix, type of fracture (and, by extension, use/ non-use of bone cement) [20] and orthogeriatric/ rehabilitative input, amongst others. 'Better' methods of anaesthesia may include the pre-operative administration of local anaesthetic nerve block [5,21] with GA or spinal anaesthesia after studies determining which type of nerve block and dose of local anaesthetic agent provide the best combination of analgesia and postoperative mobility; using lower doses of inhalational [17] or intravenous [22] general and spinal [23] anaesthesia; and administering spinal anaesthesia without sedation or with bispectral index-guided sedation [24,25].…”

Section: Discussionmentioning

confidence: 99%

Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset

2014

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Summary Large observational studies of accurate data can provide similar results to more arduous and expensive randomised controlled trials. In 2012, the National Hip Fracture Database extended its dataset to include ‘type of anaesthesia’ data fields. We analysed 65 535 patient record sets to determine differences in outcome. Type of anaesthesia was recorded in 59 191 (90%) patients. Omitting patients who received both general and spinal anaesthesia or in whom an uncertain type of anaesthesia was recorded, there was no significant difference in either cumulative five‐day (2.8% vs 2.8%, p = 0.991) or 30‐day (7.0% vs 7.5%, p = 0.053) mortality between 30 130 patients receiving general anaesthesia and 22 999 patients receiving spinal anaesthesia, even when 30‐day mortality was adjusted for age and ASA physical status (p = 0.226). Mortality within 24 hours after surgery was significantly higher among patients receiving cemented compared with uncemented hemiarthroplasty (1.6% vs 1.2%, p = 0.030), suggesting excess early mortality related to bone cement implantation syndrome. If these data are accurate, then either there is no difference in 30‐day mortality between general and spinal anaesthesia after hip fracture surgery per se, and therefore future research should focus on how to make both types of anaesthesia safer, or there is a difference, but mortality is not the correct outcome to measure after anaesthesia, and therefore future research should focus on differences between general and spinal anaesthesia. These could include more anaesthesia‐sensitive outcomes, such as hypotension, pain, postoperative confusion, respiratory infection and mobilisation.

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“…For example, a recent propensity score matched analysis of patients undergoing carotid endarterectomies found 77.0% of patients who received RA were discharged the next day, compared with only 64.4% of patients who received GA (P < 0.0001), 25 whereas a randomized trial among total knee arthroplasty patients found that GA resulted in shorter lengths of stay than spinal anesthesia. 26 With the recent increase in fast track surgery programs, the use of RA techniques can potentially offer many advantages in terms of enhanced patient recovery to support such programs. 9 Early recovery after surgery or "fast-track surgery" protocols have become more mainstream during the last decade, with significant evidence for better results.…”

Section: Discussionmentioning

confidence: 99%

Regional Anesthesia, Time to Hospital Discharge, and In-Hospital Mortality

Bulka

Shotwell

Gupta

et al. 2014

Regional Anesthesia and Pain Medicine

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Recovery After Total Intravenous General Anaesthesia or Spinal Anaesthesia for Total Knee Arthroplasty

Cited by 24 publications

References 0 publications

Postoperative orthostatic intolerance: a common perioperative problem with few available solutions

Postoperative orthostatic intolerance: a common perioperative problem with few available solutions

Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset

Regional Anesthesia, Time to Hospital Discharge, and In-Hospital Mortality

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