Reuters Health/Medscape Today—May 10, 2013
In a large retrospective study, knee and hip arthroplasty patients had better perioperative outcomes with spinal or epidural anesthesia rather than general anesthesia.
Which anesthetic technique is better has been debated for many years. Hip and knee arthroplasties are being done more frequently, so evidence-based guidance for anesthetic management is needed, but randomized trials are difficult to do because complications after these procedures are generally so infrequent.
The new conclusions are drawn from data on hundreds of thousands of cases, analyzed by investigators based at New York City's Hospital for Special Surgery. They reported their findings this month in Anesthesiology.
In an email to Reuters Health, lead author Dr. Stavros G. Memtsoudis said, "While at our hospital the use of neuraxial anesthesia for total knee and total hip arthroplasties represents standard practice, it clearly does not in many other institutions."
The authors looked at records from Premier Perspective, Inc., which oversees an administrative database comprising patients from nearly 400 hospitals, mostly non-teaching and urban institutions.
With the exceptions of cardiac and gastrointestinal complications, which occurred at similar rates in all three groups, all other adverse outcomes (pulmonary embolism, respiratory failure, pneumonia, stroke, infections, acute renal failure, and need for blood products) occurred significantly more often after general anesthesia.
Dr. Memtsoudis noted, "One of the main benefits of using large databases is the ability to study low incidence outcomes that are otherwise difficult to evaluate in prospective studies."
He noted that the incidence of pulmonary embolism after these procedures has become almost trivial over the years, which is in stark contrast to the cumulative amount of research published and effort expended to treat and prevent it. While differences may seem relatively small, the effect sizes seen in the study were "similar or larger than those achieved by many medications used to prevent adverse events in the perioperative period, for example, statins for the prevention of cardiac events."
"Over 90% of patients at Hospital for Special Surgery receive neuraxial anesthesia," Dr. Memtsoudis said.
"I believe that future research will have to investigate possible confounding factors not measured in databases," Dr. Memtsoudis said. "We have to confirm that the use of neuraxial anesthesia is not just a surrogate marker of better overall care, which may explain some of the outcomes."
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