key: cord-0967513-739k4bit
authors: Kelly, McKayla; Turcotte, Justin; Aja, Jacob; MacDonald, James; King, Paul
title: General vs. Neuraxial Anesthesia in Direct Anterior Approach Total Hip Arthroplasty: Effect on Length of Stay and Early Pain Control.
date: 2020-10-06
journal: J Arthroplasty
DOI: 10.1016/j.arth.2020.09.050
sha: 870d06dd5ba3612b0004478d8a43d27b5ee66811
doc_id: 967513
cord_uid: 739k4bit

Background. Recent literature has suggested some benefits for neuraxial anesthesia (NA) as an alternative for general anesthesia (GA) for primary total hip arthroplasty patients. We examined the impact of NA versus GA on outcomes for patients undergoing direct anterior (DA) approach total hip arthroplasty (THA) in an institution with established rapid recovery protocols. Methods. Retrospective review was conducted for 500 consecutive THA patients from a single institution. Univariate analysis and multivariate linear regression were used to compare outcomes for THA patients receiving NA and GA. Results. There was a significant difference in length of stay with NA patients having a shorter length of stay (NA 32.7 hours vs GA 38.1 hours, P=0.003). Patients receiving NA had significantly lower PACU morphine milligram equivalents (MME) (NA 10.2 MME vs GA 15.6 MME, P<0.001) and reported a lower score on the PACU pain numeric rating scale (NA 2.1 vs GA 3.7, P <0.001). Conclusion. Neuraxial anesthesia is associated with decreased LOS, decreased PACU MME, and a lower PACU pain score for patients undergoing primary DA THA. These trends remained consistent when controlling for age, sex, BMI, and ASA.

Total hip arthroplasty (THA) is one of the most frequently performed procedures in the United 25

States and its demand is expected to continuing increasing in upcoming years [1] . The direct 26 anterior approach to THA has become increasingly popular and has resulted in significant 27 improvements in quality of life outcomes for patients [2] . Although benefits to regional 28 anesthesia have been reported [3] we sought to standardize the evaluation and eliminate possible 29 confounding variables that may be introduced by including different approaches. The expanding 30 use of direct anterior THA justifies the growing need to evaluate the impact of various anesthetic 31 approaches on outcomes. 32 33 Enhanced recovery after surgery (ERAS) protocols have been shown to decrease length of stay 34 and decrease complications after total joint arthroplasty, and have become a standard of care 35 nationally [4] .Within ERAS protocols, Neuraxial anesthesia (NA) has shown promise in 36 decreasing perioperative blood loss and length of stay for THA patients [5] . Most NA agents 37 block initiation and conduction of nerve impulses by decreasing the sodium permeability of the 38 neuronal membrane causing inhibition of depolarization responsible for the sympathetic block 39 [6] .The proposed physiological reason for reduced blood loss is the role of NA in reducing 40 arterial and venous blood pressure, as hypotension has been demonstrated to reduce 41 intraoperative blood loss [5, 7] . 42 43 A number of studies have shown decreased complication rates and mortality in patients that 44 have neuraxial anesthesia for THA but the majority of these studies were performed prior to 45 consideration [8] [9] [10] . 47

This study was deemed institutional review board exempt by the institutional clinical research 50 committee. A retrospective chart review was performed of patients undergoing unilateral primary 51 total hip arthroplasty using the direct anterior approach by 4 board certified surgeons at a single 52 institution. The timeline for inclusion was between July 2017 and July 2018. Data were collected 53 using an administrative database for patient demographics (age, sex, body mass index (BMI), 54 LOS, and procedure performed). Preoperative hematocrit performed within the 30 days before 55 surgery and postoperative day 1 hematocrit were recorded and used to calculate the change in 56 hematocrit for each patient. Intraoperative fluid use and estimated blood loss were recorded 57 along with perioperative administration of dexamethasone. American Society of 58

Anesthesiologists (ASA) score was used to quantify preoperative health status. Any patient 59 readmitted to this institution or another institution in the Chesapeake Regional Informational 60 System for our Patient (CRISP) database in the first 90 days after surgery was recorded. 61 controlled analgesia and nerve blocks were not used in this patient population. Anesthesia was 70 chosen based on patient and surgeon preference, and anesthesiologist recommendation in cases 71 of medical comorbidities or previous spinal surgery. General anesthesia administration included 72 inhaled anesthetics and mechanical ventilation with intravenous opioids administered 73 intraoperatively and in the post-anesthesia care unit. Neuraxial anesthesia agents were 74 administer via a lumbar puncture with hyperbaric bupivacaine, with some patients receiving 75 intrathecal fentanyl at the anesthesiologist's discretion. NA was usually paired with propofol 76 sedation. Patients receiving NA were not intubated, mechanically ventilated, and did not receive 77 inhaled anesthetic agents. All THA patients received intraoperative fluid management, 78 periarticular local anesthetic injection before closure, intravenous or topical tranexamic acid, and 79 assisted ambulation on the day of surgery when appropriate. Day of surgery ambulation occurred 80 as standard of care unless patients had medical reason preventing safe ambulation or 81 sensory/motor function not intact after spinal anesthesia in adequate time to participate in 82 therapy. 83 84

All patients included in this study underwent direct primary unilateral THA using the direct 86 anterior approach. Patients undergoing bilateral THA, revisions, or posterolateral approach THA 87 were excluded. A total of 500 patients met inclusion criteria. All patients underwent a total hip 88 arthroplasty (THA) performed via anterior approach using a fracture table and fluoroscopy 89 between July 2017 and July 2018. Of the 500 total patients receiving THA within the study 90 timeline, 376 received NA and 124 received GA.

The primary outcome of the study was the influence of anesthesia type on LOS. Secondary 94 outcomes included PACU pain, PACU nausea, and PACU narcotic consumption, re-95 catheterization rate, and 30-day readmission rates. Perioperative measures that influence these 96 primary and secondary outcomes were also assessed. 97 98

Univariate analysis utilizing chi-squared and t-tests were used to determine differences between 100 groups. Multiple linear regression was used to establish the effect on anesthesia type on 101 perioperative and postoperative outcomes while controlling for age, sex, BMI, and ASA. These 102 variables were selected as they have each been independently associated with increased LOS and 103 complications in patients undergoing THA.

[11] ASA was used as a composite measure of to 104 control for overall comorbidity burden in this population. These same control variables were 105 used for all regression models. A P value less than or equal to 0.05 was statistically significant. 106 All statistical analyses were performed using SPSS. (SPSS 25.0, IBM Inc, Somers, NY) 107 P <0.001). There were no significant differences in BMI or average age between NA and GA 116 patients. (Table 1) In alignment with prior studies, we suggest an explanation for decreased LOS in NA patients 181 could be improved facilitation of early mobilization compared to GA due to reduced 182 postoperative pain and side effects such as postoperative nausea, vomiting, drowsiness and may influence ability to ambulate early as pain control is a main requirement for early 185 ambulation. In addition to achievement of pain control prior to ambulation, our institutional 186 protocol requires patients to have stable vitals, be alert and oriented, and have regained sensory 187 and motor function. The relationship between NA and decreased LOS observed in our trial is 188 further strengthened by the rates of dexamethasone use in the NA and GA groups. In a previous 189 controlled trial, Dexamethasone contributed to lower pain scores and a shorter length of stay 190 following total joint arthroplasty.

[23] Despite receiving dexamethasone more frequently, GA 191 patients still had a higher pain score and a longer length of stay compared to NA patients in our 192 population. 193 194 In this patient cohort, NA was performed in the operating room, immediately prior to patient 195 positioning. Despite anecdotal concerns that NA would increase total OR time compared to GA, 196 in this study patients with NA had shorter non-procedure operating room time. improve the efficiency of THA with NA. In our study, surgeon perception of blood loss, as 206 confirmed by a statistically significant reduction in change in hematocrit, which is a better 208 measure of actual blood loss than the inherently subjective EBL. We therefore suggest our study 209 does not provided adequate support to establish a link between NA and reduced blood loss. 210 211 Our findings demonstrate a significant difference in ASA between NA and GA groups with GA 212 patients more likely to have a higher ASA score. NA is considered contraindicated in patients 213 who suffer from medical conditions such as aortic stenosis or hypotension, and these conditions 214 contribute to an elevated ASA score.

[19] These medical conditions also contribute to an 215 elevated ASA score. The significant difference in ASA scores between the GA and NA groups 216 could be explained by the clinical choice to use general anesthesia for patients who may require 217 airway control due to preexisting medical conditions. Despite this, the trends in postoperative 218 outcomes remained significantly different between NA and GA groups when controlling for 219

The impact of NA on outcome for TJA patients has been debated.

[26] Some authors have 221 demonstrated no significant difference in outcomes between NA and GA [26, 27] , yet others have 222 demonstrated a reduced risk of complications and a decreased operative cost associated with NA. 223 [13, 14, [27] [28] [29] Despite the lack of consensus, the popularity of NA for orthopedic patients has 224 continued to increase in recent years with expedited growth in the outpatient setting. [30, 31] The 225 recent removal of TKA and THA from the Centers for Medicare and Medicaid Services in-226 patient only list, promotes the exploration of possible methods facilitating a shorter hospital stay 227 while maintaining high standards of care. [28, 32] Our results support the assertion that neuraxial 228 anesthesia may facilitate the safe transition of THA to the outpatient setting. While our center 229 discharges in a subset of patients that were carefully selected by the surgeon in consultation with 231 the patient and their caregiver. Of the 24 patients discharged on the day of surgery, 23 received 232 neuraxial anesthesia, and this has become the standard of care for all same day discharges at our 233 institution. Based on the early success of same day discharge using neuraxial anesthesia, we have 234 expanded our program to perform over 20% of THAs with same day discharge and began 235 performing cases in the ambulatory surgery center setting. 236

The main limitation of this study is that it is a retrospective review conducted at a single 237 institution. First, the findings of this study may not be representative of the larger patient 238 population due to the small sample size and selection bias. Of particular importance, it is 239 possible that more surgically complex cases were preferentially placed under general anesthesia, 240

if OR time was anticipated to be longer than could be adequately anesthetized with NA. Due to 241 the multiple factors that influence case complexity, we were unable to specifically control for 242 this in our population. However, our results suggest that case complexity was not used as an 243 indicator for GA in our population. BMI, which can be an indicator of more challenging cases, 244 was equivalent between the two groups. Further, NA has a duration of action of 90-150 minutes. 245 [19,20] J o u r n a l P r e -p r o o f 

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