No Clinical Difference Comparing General, Regional, and Combination Anesthesia in Hip Arthroplasty: A Multicenter Cohort-Study Regarding Perioperative Pain Management and Patient Satisfaction

doi:10.1016/j.arth.2017.05.038

The Journal of Arthroplasty

Volume 32, Issue 11, November 2017, Pages 3429-3433

https://doi.org/10.1016/j.arth.2017.05.038 Get rights and content

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.

Section snippets

Materials and Methods

From 2009-2015, 18,118 patients were evaluated after undergoing hip arthroplasty in the present cohort study, which was conducted nationwide in 49 orthopedic departments at the time of data evaluation (Fig. 1). All hip arthroplasties meeting the exclusion and/or inclusion criteria (see below) were evaluated, independently on the diagnosis necessitating the surgical procedure. A multidisciplinary team of anesthetists, orthopedic surgeons, and nurses realized the regular procedure of analyzing

Results

A total of 18,118 patients were included and evaluated after receiving hip arthroplasty between 2009 and 2015 in this study.

Mean age regarding all patients was 66.9 years (±11.2), 57.6% of all patients were women, the median American Society of Anesthesiologists score was 2 (interquartile range 2-3). Mean duration of surgery was 79 minutes (±32) in all three groups.

The three groups in question, demographic and general data were homogenous (Table 1).

Mean activity pain was 4.2 (±2.3) in the

Discussion

The most important findings of the present study were the superiority of the use of regional or combined general and regional anesthesia, when comparing general, regional, and combined general and regional anesthesia regarding need for pain medication, patient-reported functional parameters as well as pain scores and patient's satisfaction.

Hip arthroplasty is a very stressful surgical intervention for patients [3]. Severe pain postoperatively, prolonged hospital stays with delayed mobility, and

Conclusions

In summary, we showed in a large number of patients in clinical routine that regional as well as combining regional and general anesthesia during hip arthroplasty has some advantages in postoperative need for pain medication, functional parameters, pain scores, and patient satisfaction, although differences were relatively small.

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Spinal anesthesia is increasingly used in complex patient populations including revision total hip arthroplasties (THAs). This study aimed to investigate the pain control, length of stay (LOS), and complications associated with spinal versus general anesthesia in a large institutional series of revision THAs.
We retrospectively identified 4,767 revision THAs (4,533 patients) from 2001 to 2016 using our institutional total joint registry. Of these cases, 86% had general and 14% had spinal anesthesia. Demographics between groups were similar with mean age of 66 years, 52% women, and mean body mass index of 29. Complications including all-cause rerevisions and reoperations were studied. Data were analyzed using an inverse probability of treatment weighted model based on propensity score that accounted for patient and surgical factors. The mean follow-up was 7 years.
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Citation Excerpt :
Patients were satisfied with their anesthetic treatment in the both groups, but those treated with regional anesthesia were more likely to choose general anesthesia if operated again [30]. A large multicenter study by Greimel et al (2017) showed that THA with regional anesthesia alone or combined with general anesthesia has beneficial effect on the postoperative pain scores, analgesic use, functional parameters, and patient satisfaction compared with the general anesthesia alone, but the differences between the groups were relatively small [2]. Spinal anesthesia may be a preferable choice for elderly people as general anesthesia carries a risk for postoperative cognitive dysfunction [31] but many contraindications preclude regional anesthesia in these patients [32].
Patients undergoing total hip arthroplasty (THA) need substantial amount of opioids for postoperative pain management, which necessitates opioid-sparing modalities. Dexmedetomidine is a novel alpha-2-adrenoceptor–activating drug for procedural sedation. In addition to its sedative effect, dexmedetomidine has analgesic and antiemetic effects. We evaluated retrospectively the effect of intraoperatively administered intranasal low-dose dexmedetomidine on postoperative opioid requirement in patients undergoing THA.
We included 120 patients with American Society of Anesthesiologists status 1-2, age between 35 and 80 years, and scheduled for unilateral primary THA under general anesthesia with total intravenous anesthesia. Half of the patients received 50 μg of intranasal dexmedetomidine after anesthesia induction, while the rest were treated conventionally. Postoperative opioid requirements were calculated as morphine equivalent doses for both groups. The impact of intranasal dexmedetomidine on postoperative hemodynamics and length of stay was evaluated.
The cumulative postoperative opioid requirement was significantly reduced in the dexmedetomidine group compared with the control group (26.3 mg, 95% confidence interval 15.6-36.4, P < .001). The cumulative dose was significantly different between the groups already at 12, 24, and 36 h postoperatively (P = .01; P = .001; P < .001, respectively). Dexmedetomidine group had lower mean arterial pressure in the postanesthesia care unit compared with the control group (P = .01). There was no difference in the postanesthesia care unit stay or postoperative length of stay between the two groups (P = .47; P = .10, respectively).
Compared with the control group, intraoperative use of intranasal low-dose dexmedetomidine decreases opioid consumption and sympathetic response during acute postoperative period in patients undergoing THA.
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: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.05.038.

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Primary ArthroplastyNo Clinical Difference Comparing General, Regional, and Combination Anesthesia in Hip Arthroplasty: A Multicenter Cohort-Study Regarding Perioperative Pain Management and Patient Satisfaction

Abstract

Background

Methods

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Conclusions

Br J Anaesth

J Clin Anesth

J Arthroplasty

Br J Anaesth

Lancet

Pain

Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials

BMJ

Perioperative comparative effectiveness of anesthetic technique in orthopedic patients

Anesthesiology

Procedure-specific risk factor analysis for the development of severe postoperative pain

Anesthesiology

Comparative effectiveness research panel at the 2012 Advertising & Promotion Conference of the Food & Drug Law Institute

Food Drug L J

Improving hip fractures outcomes for COPD patients

COPD

Perioperative outcomes and type of anesthesia in hip surgical patients: an evidence based review

World J Orthop

Regional anaesthesia and blood loss

Acta Anaesthesiol Scand Suppl

Anesthetic management and surgical site infections in total hip or knee replacement: a population-based study

Anesthesiology

A comparison of regional and general anaesthesia for total replacement of the hip or knee: a meta-analysis

J Bone Joint Surg Br

Spinal versus general anesthesia for orthopedic surgery: anesthesia drug and supply costs

Anesth Analg

Utilization of critical care services among patients undergoing total hip and knee arthroplasty: epidemiology and risk factors

Anesthesiology

Primary Arthroplasty
No Clinical Difference Comparing General, Regional, and Combination Anesthesia in Hip Arthroplasty: A Multicenter Cohort-Study Regarding Perioperative Pain Management and Patient Satisfaction