Combined regional and general anesthesia for orthopedic spine fusion surgery

The combination of epidural anesthesia and general anesthesia is a sophisticated technique that offers many advantages for the patient undergoing lumbar spine fusion. With a proper understanding of the physiological and pharmacological considerations of this technique, it can be used to aggressively lower blood pressure intraoperatively, minimizing blood loss and maximizing the condition of the surgical field. Optimal postoperative pain management can be achieved with minimal side effects. The circulatory and cardiac effects of epidural hypotension must be appreciated before embarking on the use of this technique. The extensive sympathetic blockade achieved must be controlled by support of the circulation with an infusion of epinephrine. The technique involves a combination of a high-level epidural anesthetic using bupivacaine or ropivacaine. For safety, this is started before the induction of general anesthesia. Continuous monitoring of both intraarterial and central venous pressures must be performed to avoid precipitous hypotension and sudden bradycardia. Mean arterial pressure is targeted and controlled in the 50 to 60 mm Hg range. A light, general anesthetic with a nitrous narcotic technique is used to supplement the epidural. Epidural anesthesia alone has been found to diminish intraoperative blood loss by significant volumes. Epidural hypotensive anesthesia with proper technique further reduces blood loss, decreases the incidence of deep venous thrombosis, and is associated with an extremely low complication rate. This has been shown by numerous studies on patients who had total hip arthroplasties. Extensive epidural anesthesia applied to lumbar spine fusion surgery theoretically can achieve these same advantageous outcomes. Copyright © 2000 by W.B. Saunders Company     

The effect of regional anesthesia blocks on post-operative pain after ambulatory orthopedic trauma surgery

European Journal of Orthopaedic Surgery & Traumatology - To determine if regional anesthesia had added benefit to general anesthesia, with or without local anesthesia, in controlling...     

Efficacy of warfarin reversal in orthopedic trauma surgery patients

OBJECTIVES: We determine the efficacy of active reversal of warfarin anticoagulation with intravenous vitamin K compared to withholding warfarin in patients requiring urgent orthopedic trauma surgery. DESIGN: This was a prospective cohort with immediate prehypothesis consecutive retrospective comparative case series conducted at a level 1 university hospital trauma unit. PATIENTS: Forty-eight consecutive patients between 1998 and 2004 in a study composed of a prospective cohort were compared with a retrospective consecutive case series of warfarinized orthopedic trauma patients requiring urgent surgery. The prospective arm directly followed the historic case series from which the hypothesis was generated. INTERVENTION: Vitamin K administration. MAIN OUTCOME MEASURES: Primary outcome was time to surgery. Secondary outcomes were problems with active reversal, length of time for warfarin stabilization after surgery, and complications. RESULTS: The mean time to surgery in warfarinized patients not given vitamin K was 111.9 hours; in the intervention group, it was 67.4 hours, giving a mean difference of 44.5 hours (P = 0.01). Vitamin K reduced the international normalized ratio (INR) to less than 2.0 in 74% of patients within 24 hours. There were no complications of vitamin K administration. A dose of vitamin K costs approximately 1/1000 of a hospital bed day cost. A loading dose of warfarin on the second postoperative day took approximately 1 day longer to reach an INR of greater than 2.0 in the intervention patients than in those who had not been given vitamin K. CONCLUSIONS: Warfarin reversal with vitamin K was successful and facilitated earlier surgery in all patients; the first dose was effective in approximately three quarters of patients. It is cost-effective, with no side effects caused in this study.     

Use of direct oral anticoagulants with regional anesthesia in orthopedic patients

The use of direct oral anticoagulants including apixaban, rivaroxaban, and dabigatran, which are approved for several therapeutic indications, can simplify perioperative and postoperative management of anticoagulation. Utilization of regional neuraxial anesthesia in patients receiving anticoagulants carries a relatively small risk of hematoma, the serious complications of which must be acknowledged. Given the extensive use of regional anesthesia in surgery and the increasing number of patients receiving direct oral anticoagulants, it is crucial to understand the current clinical data on the risk of hemorrhagic complications in this setting, particularly for anesthesiologists. We discuss current data, guideline recommendations, and best practice advice on effective management of the direct oral anticoagulants and regional anesthesia, including in specific clinical situations, such as patients undergoing major orthopedic surgery at high risk of a thromboembolic event, or patients with renal impairment at an increased risk of bleeding.     

Epidural anesthesia prevents hypercoagulation in patients undergoing major orthopedic surgery

BACKGROUND AND OBJECTIVES: Epidural anesthesia (EA) is known to reduce postoperative thromboembolic complications, but mechanisms are incompletely understood. In this study, we tested the hypothesis that local anesthetics (LA) prevent postoperative hypercoagulability without affecting physiologic aggregation and coagulation processes. METHODS: Clot signature analysis (CSA) was used to assess platelet and clotting function. Venous blood samples were collected pre- and postoperatively from 41 patients undergoing major orthopedic surgery. The effect of surgery on 3 CSA parameters (platelet-mediated hemostasis time [PHT], clotting time [CT], and collagen-induced thrombus formation [CITF]) was determined in patients receiving EA (n = 20) and those receiving general anesthesia (GA) (n = 21). RESULTS: In the GA group, orthopedic surgery induced a hypercoagulable state: PHT was reduced by 39% +/- 8.6% (P <.001), CT by 21% +/- 3.3% (P <.001), CITF by 10.3% +/- 5.9% (P =.06) compared with respective baseline values. In the EA group, by contrast, no parameter was altered significantly, but PHT showed a tendency towards prolongation by 33.2% +/- 15.4% (P =.25). CT changed by 0% +/- 4.4% (P =.89), CITF by 3.8% +/- 7% (P =.78). CONCLUSIONS: Use of EA prevents immediate postoperative hypercoagulability without affecting physiologic aggregation and coagulation processes. Also, CSA appears useful in predicting hypercoagulability and detecting platelet dysfunction. Reg Anesth Pain Med 2001;26:215-222.     

Closed-loop control of anesthesia using Bispectral index: performance assessment in patients undergoing major orthopedic surgery under combined general and regional anesthesia.

BACKGROUND: The Bispectral Index (BIS) is an electroencephalogram-derived measure of anesthetic depth. A closed-loop anesthesia system was built using BIS as the control variable, a proportional-integral-differential control algorithm, and a propofol target-controlled infusion system as the control actuator. Closed-loop performance was assessed in 10 adult patients. METHODS: Ten adult patients scheduled to undergo elective hip or knee surgery were enrolled. An epidural cannula was inserted, and 0.5% bupivacaine was used to provide anesthesia to T8 before general anesthesia was induced using the propofol target-controlled infusion system under manual control. After the start of surgery, when anesthesia was clinically adequate, automatic control of anesthesia was commenced using the BIS as the control variable. Adequacy of anesthesia during closed-loop control was assessed clinically and by calculating the median performance error, the median absolute performance error, and the mean offset of the control variable. RESULTS: The median performance error and the median absolute performance error were 2.2 and 8.0%, respectively. Mean offset of the BIS from the set point was 0.9. Cardiovascular parameters were stable during closed-loop control. Operating conditions were adequate in all patients but one, who began moving after 45 min of stable anesthesia. No patients reported awareness or recall of intraoperative events. In three patients, there was oscillation of the measured BIS around the set point. CONCLUSIONS: The system was able to provide clinically adequate anesthesia in 9 of 10 patients. Further studies are required to determine whether control performance can be improved by alterations to the gain factors or by using an effect site-targeted, target-controlled infusion propofol system.     

Balanced regional anesthesia for hand surgery

In summary, the clinical goal in regional anesthesia for hand surgery is to constantly approach the ideal of a well-conducted, smooth, "balanced regional technique." This begins with the preoperative interview, assurance, and preoperative sedation (po). In the operating room, monitoring (EKG, BP) and safety measures (IV port, nasal oxygen) precede the regional technique. The block is performed with asepsis, minimal "needling," and correct dosages. The complement to neural blockade anxiolytic medication is titrated, thus the balance of IV sedation and regional block is achieved. The patient's symptoms, vital signs, and general comfort should be attended to during the hand surgery. Monitoring is continued in the recovery room, where special attention is given to positioning, cushioning of pressure areas, dressing, analgesia, and specific physical rehabilitation exercises. With a "balanced regional technique," the patient becomes an early participant in his or her own postoperative care and result. This balanced technique reduces the patient's overall operative risk and maximizes the surgical result.     

Interscalene regional anesthesia for shoulder surgery

BACKGROUND: Despite a trend toward the use of regional anesthesia for orthopaedic procedures, there has been resistance to the use of interscalene regional block for shoulder surgery because of concerns about failed blocks and potential complications. METHODS: We retrospectively reviewed the cases of 568 consecutive patients who had shoulder surgery under interscalene regional block in a tertiary-care, university-based practice with an anesthesiology residency program. The blocks were performed by a group of anesthesiologists who were dedicated to the concept of regional anesthesia in their practice. Complete anesthetic and orthopaedic records were available for 547 patients. The surgical procedure, planned type of anesthesia, occurrence of block failure, and the presence of complications were noted. RESULTS: Of the 547 patients, 295 underwent an arthroscopic procedure and 252 (including eighty who had an arthroplasty) underwent an open procedure. General anesthesia was the initial planned choice for sixty-nine patients because of the complexity or duration of the procedure, the anatomic location, or patient insistence. Thirty-four of the sixty-nine patients also received an interscalene regional block. Interscalene regional block alone was planned for 478 patients. A total of 462 patients (97%) had a successful block whereas sixteen required general anesthesia because the block was inadequate. The success of the block was independent of the type or length of the surgery. No patient had a seizure, pneumothorax, cardiac event, or other major complication. Twelve (2.3%) of the 512 patients who had a block had minor complications, which included sensory neuropathy in eleven patients and a complex regional pain syndrome that resolved at three months in one patient. For ten of the eleven patients, the neuropathy had resolved by six months. CONCLUSIONS: Interscalene regional block provides effective anesthesia for most types of shoulder surgery, including arthroplasty and fracture fixation. When administered by an anesthesiologist committed to and skilled in the technique, the block has an excellent rate of success and is associated with a relatively low complication rate.     

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

Total hip or knee replacement surgeries are common orthopedic interventions that can be performed with spinal anesthesia (SA) or general anesthesia (GA). No study has investigated the economic aspects associated with the two anesthetic techniques for this common surgery. We randomized 40 patients to receive either SA or GA and analyzed the drug and supply costs for anesthesia und recovery. Anesthesia-related times, hemodynamic variables, and pain scores were also recorded. Total costs per case without personnel costs were almost half in the SA group compared with the GA group; this was a result of less cost for anesthesia (P < 0.01) and for recovery (P < 0.05). This finding was supported by a sensitivity analysis. There were no relevant differences regarding anesthesia-related times. Patients in the GA group were admitted to the postanesthesia care unit with a higher pain score and needed more analgesics than patients in the SA group (both P < 0.01). We conclude that SA is a more cost-effective alternative to GA in patients undergoing hip or knee replacement, as it is associated with lower fixed and variable costs. Moreover, SA seems to be more effective, as patients in the SA group showed lower postoperative pain scores during their stay in the postanesthesia care unit.     

Continuous intradural anesthesia in geriatric patients undergoing orthopedic and traumatologic surgery]

OBJECTIVES. The aim of the study was to prospectively evaluate the results of continuous intradural anesthesia with 18G Tuohy needle and 20G catheter in geriatric patients. MATERIAL AND METHODS. We studied 70 patients with a mean age of 75.9 +/- 10.8 years who were subjected to orthopedic or traumatologic surgery of the lower extremities with a duration of 104.6 +/- 53.6 min. RESULTS. Success index was 95.7%. The initial dose of 1% tetracaine was 10.36 +/- 3.96 mg, the second dose in 29 patients was 7.2 +/- 2.7 mg, the third in 7 cases was 7.40 +/- 2.47 mg, and the total dose was 14.56 +/- 5.6 mg. The metameric level was between T8 and T11 in 80.32% of patients. Peroperative complications were limited to paresthesia in 5 cases (7.14%) during insertion of the catheter, difficulties in catheter placement in one case (1.42%), and accidental catheter extraction during withdrawal of the needle in 2 cases (2.85%). Ten patients (14.28%) presented arterial hypotension (pressure decrease greater than 30% of baseline systolic arterial pressure). During the postoperative phase there were 3 cases of slight headache after dural puncture (4.28%) that recovered with conservative treatment, and one case of lumbalgia at the puncture zone (1.42%). CONCLUSIONS. Continuous intradural anesthesia with the material used in this study is technically easy. It allows to accurately reach the desired metameric level, avoiding massive sympathetic blockade, and providing a steady hemodynamic condition. All these effects are essential for anesthesia in geriatric patients.