11

The choice of anaesthetic in The choice of anaesthetic in primary total hip replacement primary total hip replacement

surgery – which gives the best surgery – which gives the best perioperative outcome?perioperative outcome?

22

OverviewOverview Definition of GA and RADefinition of GA and RA Anaesthetic options for primary THRAnaesthetic options for primary THR RA vs GARA vs GA Factors affecting choice of Factors affecting choice of

anaestheticanaesthetic ConclusionConclusion

33

DefinitionsDefinitions

General AnaesthesiaGeneral AnaesthesiaAbsence of cerebral response to noxious Absence of cerebral response to noxious stimulation by means of drugs, usually stimulation by means of drugs, usually given via IV or inhalational routegiven via IV or inhalational route

Regional AnaesthesiaRegional AnaesthesiaSelective denervation of part of the body Selective denervation of part of the body by administration of local anaesthetics by administration of local anaesthetics around the nervearound the nerve

Ref 6

44

Anaesthetic Options for 1Anaesthetic Options for 1oo THR THR GAGA

RA (+/- sedation)RA (+/- sedation)• Spinal - single shot (or continuous)Spinal - single shot (or continuous)• Epidural – continuous (or single shot)Epidural – continuous (or single shot)• Combined spinal epiduralCombined spinal epidural• Lumbar and sacral plexus blocks - single shot Lumbar and sacral plexus blocks - single shot

(with/without catheter)(with/without catheter)

Combination of GA/RACombination of GA/RARef 7

55

DVT 2

PE 2

BTR 9

OR of 1 = No difference in odds of DVT/PE/BTR* between RA and GA

Increasing protective effect of RA on DVT/PE incidence and BTR

*BTR = Blood Transfusion Requirement

2 Meta-analysis of Spinal or Epidural vs GA9 Spinal vs GA

Clinical Advantages of RA (1)Clinical Advantages of RA (1)

66

Reduced intra-operative blood lossReduced intra-operative blood loss• 275ml/case (95% CI 180-371 ml) 275ml/case (95% CI 180-371 ml) 22

Better immediate postoperative Better immediate postoperative analgesia analgesia 44

• Pre-requisite for successful rehabilitation Pre-requisite for successful rehabilitation 88

2 Spinal or Epidural vs GA 4 Spinal vs GA

Clinical Advantages of RA (2)Clinical Advantages of RA (2)

77

Advantages of RA (3)Advantages of RA (3) Reduced total cost per case Reduced total cost per case 44

• Less cost for anaesthesia (p<0.01)Less cost for anaesthesia (p<0.01)• Less cost for recovery (p<0.05)Less cost for recovery (p<0.05)

Patients regain mental acuity quicker Patients regain mental acuity quicker 1010

Fewer drugs usedFewer drugs used

4 Spinal vs GA

88

Disadvantages of RA Disadvantages of RA 22

Takes longerTakes longer Failure of blockFailure of block GAGA Urinary retentionUrinary retention Potential for CVS instabilityPotential for CVS instability

X

99

Advantages of GA Advantages of GA 11,1511,15

Faster techniqueFaster technique Patient preference to not be awakePatient preference to not be awake

1010

Disadvantages of GA Disadvantages of GA 1111

Slower recovery from sedationSlower recovery from sedation Increased post op respiratory infectionIncreased post op respiratory infection Requires immediate post op Requires immediate post op

sedative/analgesiasedative/analgesia Increased post op nauseaIncreased post op nausea

X

1111

Choice of anaestheticChoice of anaesthetic Co-morbiditiesCo-morbidities Anaesthetic HistoryAnaesthetic History DrugsDrugs AllergiesAllergies AirwayAirway

1212

ConclusionConclusion Evidence that RA better Evidence that RA better

perioperative outcome:perioperative outcome:• Lower DVT/PELower DVT/PE• Reduced blood transfusion requirementReduced blood transfusion requirement• Better post-operative analgesiaBetter post-operative analgesia

Choice of anaesthetic depends on Choice of anaesthetic depends on many factors and alters with each many factors and alters with each patientpatient

1313

ReferencesReferences1. National Joint Registry “National Joint Registry Annual Report 2005-2006”, downloaded from www.njrcentre.org.uk, on 18th

July 2007.2. Mauermann WJ, Shilling AM, Zuo Z “A comparison of neuraxial block versus general anesthesia for elective total hip

replacement: A meta-analysis” Regional Anesthesia (2006) 103:1018-1025.3. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zunderet A, Sage D, Futter M, Saville G, Clark T, MacMahon S

“Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials” BMJ (2000) 321:1-12.

4. Gonano C, Leitgeb U, Sitzwohl C, Ihra G, Weinstabl C, Kettner SC “Spinal versus General Anaesthesia for Orthopaedic Surgery: Anaesthesia Drug and Supply Costs” Anaesthesia and Analgesia (2006) 102:524-529.

5. Francesco Indelli P, Grant SA, Nielsen K, Parker Vail T “Regional Anaesthesia in Hip Surgery” Clinical Orthopaedics and Related Research (2005) 441:250-255.

6. Cousins M, Bridenbaugh P “Neural blockade in clinical anaesthesia and management of pain” 2nd edition (1988). Philadelphia: J B Lippincott.

7. Eroglu A, Uzunlar H, Erciyes N “Comparison of hypotensive epidural anaesthesia and hypotensive total intravenoue anesthesia on intraoperative blood loss during total hip replacement” Journal of Clinical Anesthesia (2005) 17:420-425.

8. European Society of Regional Anaesthesia and Pain Therapy “Procedure Specific Postoperative Pain Management”, Accessed at: http://www.postoppain.org/frameset.htm on 15th December 2007.

9. Rashiq S, Finegan BA “The effect of spinal anesthesia on blood transfusion rate in total joint arthroplasty” Canadian Journal of Surgery (2006) 49(6):391-396.

10. Sharrock NE, Fischer G, Goss S, et al “The early recovery of cognitive function after total hip replacement under hypotensive epidural anaesthesia” Reg Anesth Pain Med (2005) 30:123-127.

11. Auroy Y, Narchi P, Messiah A, et al “Serious complications related to regional anaesthesia” Anesthesiology (1997) 87:479-486.

12. Robinson N, Hall G “How to Survive in Anaesthesia” 2nd edition (2002) BMJ Books.13. http://home.satx.rr.com/altitudedcs/radical.htm14. http://www.cartoonstock.com/lowres/jwe0318l.jpg15. Bromhead H “Anaesthesia for Total Hip Replacement” Accessed at:

http://www.anaesthesiauk.com/article.aspx?articleid=100977 on 8th January 2008.