Anesthesia type affects outcomes of bilateral knee replacement surgery

October 26, 2012

Using regional anesthesia rather than general anesthesia reduces the need for blood transfusions in patients undergoing bilateral total knee replacement, according to a new study by researchers at Hospital for Special Surgery, in New York City.

Currently, the majority of bilateral knee replacements in the United States (as well as single knee replacements) are performed under general anesthesia, and researchers say that a known as neuraxial anesthesia should be promoted for these procedures.

"The use of neuraxial anesthesia may not always be feasible in every patient, but it should be considered more frequently," said Stavros Memtsoudis, M.D., Ph.D., director of Critical Care Services at Hospital for (HSS) in New York City, who led the study. "You shouldn't be asking doctors who don't use neuraxial anesthesia in their daily practice to suddenly switch over and start doing it, but there is a lot of education that needs to be done in terms of training residents and to point out the impact of the choice of anesthetic technique on outcomes beyond the operating room." The study appears online ahead of print in the journal Regional Anesthesia and .

Despite its advantages, bilateral is associated with an increased risk of complications, compared with the alternative of operating on one knee at a time. Neuraxial anesthesia involves injecting medication into the that surrounds the in the spine (known as an epidural) or into the that surrounds the spinal cord.

For the last two decades, HSS has increasingly used regional anesthesia for , because of a growing body of evidence showing favorable results compared with general anesthesia.

Because the influence of anesthesia on perioperative outcomes after bilateral total knee replacement is unknown, researchers at Hospital for Special Surgery conducted a retrospective review of all bilateral knee replacements performed between 2006 and 2010 using Premier Perspective. This administrative database contains discharge information from approximately 400 acute care hospitals located throughout the United States. The study population included 22,253 patients, but the type of anesthesia used was unclear in 6,566 of the patients. Of the 15,687 patients where anesthesia type could be identified, 6.8% received neuraxial anesthesia, 80.1% received general anesthesia, and 13.1% received a combination of both. The three groups had similar comorbidity burdens.

The investigators discovered that patients receiving neuraxial anesthesia were less likely to receive blood transfusions (28.5%) than patients receiving general anesthesia (44.7%) or the combination (38.0%) (P<0.0001). The researchers identified a trend toward a reduction in major complications, such as pulmonary embolism and mechanical ventilation, with the use of neuraxial anesthesia compared with the other two groups, but this was not statistically significant. The investigators say it is possible that the sample size was too small to find other differences in complication rates, with only 1,066 patients receiving neuraxial anesthesia.

"This study shows the important role that anesthesia plays in terms of perioperative outcomes and that people need to start looking at interventions to reduce complications of bilateral knee replacements, not just patient selection, which is basically the only thing that doctors have been advocating in the last ten years," said Dr. Memtsoudis.

In recent years, clinicians have been selecting younger patients for bilateral procedures, a practice that by itself may unfortunately be limited in its impact on complications, as it is counteracted by increasing rates of comorbidities, such as obesity, present in orthopedic patients and in the population in general [put link to other Memtsoudis press release]. "You can try to choose healthier people, but that is only going to get you so far," said Dr. Memtsoudis. "Implementing active interventions, such as selecting a specific anesthetic in order to improve outcomes may be something that we need to do more of."

Dr. Memtsoudis pointed out that communication with patients is key. "Many patients don't like the idea of having an injection in their back and their legs being numb, and they are worried about paralysis. There is a lot of misinformation out there," he said. "You have to take into account comorbidities, patient preferences and other practice specific factors, such as the choice for anticoagulation, but neuraxial anesthesia should at the very least be considered in every patient."

The price tags associated with neuraxial and are similar. medications used during surgeries are a small fraction of overall health care costs.

More work is needed to identify ways to prevent complications in patients undergoing bilateral knee replacement and a recent conference at Hospital for Special Surgery, chaired by Dr. Memtsoudis, is aiming to do just that. The Consensus Conference on the Creation of Guidelines for Bilateral Knee Arthroplasty involved 40 experts from 16 institutions. The guidelines coming out of this conference, which are expected to be published within the next six months, address issues such as selecting appropriate candidates, determining the appropriate workup and management for a patient undergoing bilateral knee replacement, and how long doctors should wait between procedures if a patient undergoes two operations.

Explore further: Growing popularity of hip and knee replacement surgery places extra burden on critical care services

Related Stories

Growing popularity of hip and knee replacement surgery places extra burden on critical care services

June 5, 2012
Roughly 3 percent of patients who undergo total hip and knee replacement surgery require critical care services before they are discharged from the hospital, according to an analysis of roughly half a million patients. The ...

Researchers show benefits of local anesthesia after knee replacement surgery

February 10, 2012
Researchers at the Rothman Institute at Jefferson have shown that local anesthesia delivered through a catheter in the joint, intraarticularly, may be more beneficial than traditional opioids such as morphine and Oxycontin ...

Cold-air anesthesia reduces pain of laser treatment

June 22, 2012
(HealthDay) -- In ablative fractionated carbon-dioxide (CO2) laser treatment for photoaging, cold-air anesthesia used in conjunction with topical anesthesia reduces pain significantly more than topical anesthesia alone, according ...

Study identifies patients at increased risk after bilateral knee replacement surgery

July 14, 2011
A new study by researchers at Hospital for Special Surgery has identified patients who are at a higher risk of morbidity and mortality when undergoing knee replacement surgery in both legs at the same time. The study found ...

Regional anesthesia reduces complications and death for hip fracture patients

June 20, 2012
In a study of more than 18,000 patients having surgery for hip fracture, researchers at the Perelman School of Medicine at the University of Pennsylvania found that the use of regional anesthesia versus general anesthesia, ...

Recommended for you

One weight-loss surgery shows lasting results

September 21, 2017
(HealthDay)—Obesity surgery can have long-lasting effects on weight and the risk of developing type 2 diabetes and high blood pressure, a new study finds.

Hold the phone: An ambulance might lower your chances of surviving some injuries

September 20, 2017
Victims of gunshots and stabbings are significantly less likely to die if they're taken to the trauma center by a private vehicle than ground emergency medical services (EMS), according to results of a new analysis.

Surgeons have major influence on breast cancer treatment

September 13, 2017
A woman's choice of surgeon plays a significant role in whether she's likely to receive an increasingly popular aggressive breast cancer surgery.

Some thyroid cancer patients can safely delay surgery

September 4, 2017
Most people diagnosed with cancer want to start treatment as soon as possible, for fear that delaying care will allow their tumor to grow out of control.

Obese people lack cells with satiety hormones

August 29, 2017
Individuals with severe overweight have an inhibited sense of satiation - they release fewer satiety hormones than people of normal weight. The reason: the responsible cells in the gastrointestinal tract of obese people are ...

Anesthesia and surgery during infancy may impact white matter during childhood

August 24, 2017
General anesthesia and surgery in otherwise healthy infants under the age of 1 year old could be associated with decreases in the amount of white matter in the brain, as well as reductions in the remaining white matter's ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.