General anaesthesia versus spinal anaesthesia for fast-track total hip arthroplasty

Study Type: Therapy
OE Level of Evidence: 2
Journal Level of Evidence: N/A
Dr. Harsten discusses the possible benefits of general anaesthesia in total hip arthroplasty.
118 patients undergoing fast-track total hip arthroplasty (THA) were randomized to receive general anaesthesia (GA), with propofol and remifentanil, or spinal anaesthesia (SA). The purpose of the study was to compare these two anaesthetic approaches in terms of length of hospital stay (LOS), short-term outcomes of well-being, and patient satisfaction at 6 months. Results indicated that Please login to view the rest of this report. Please login to view the rest of this report.
Funding: Non-Industry funded
Sponsor: Funded through Institutional grants.
Conflicts: None disclosed
Why was this study needed now?
Either general or regional anaesthesia can be used in total hip arthroplasty (THA). Spinal anaesthesia (SA), a regional anaesthetic approach, has been increasingly used in THA, with effectiveness displayed for controlling pain immediately following surgery. However, there has not been much research looking at its efficacy in comparison to a modern general anaesthesia (GA) technique, particularly in the case of fast-tracked patients. The purpose of this study was thus to measure the efficacy was to compare these two methods of anaesthesia in patients undergoing fast-track THA.
What was the principal research question?
How do general and spinal anaesthesia compare with respect to length of hospital stay (LOS), outcomes of well-being, and patient satisfaction in fast-track total hip arthroplasty (THA)?
Population: 120 patients with American Society of Anesthesiologists (ASA) physical status I-III (Age 45-85) who were undergoing fast-track total hip arthroplasty (THA). The surgery was performed with the patient in lateral position, and making use of the posterior approach. All procedures were performed through a posterior approach with a standardized technique. Patients received oral celecoxib 400 mg and paracetamol 1 g at 1 hour preoperatively. Following the surgery, 200 mg celecoxib was given every 12 hours and 1 g paracetamol was administered every 6 hours. Patient controlled analgesia (PCA) with morphine was begun at the end of the procedure, with doses of 20ug/kg administered with a 10min lockout. Oxycodone (OxyNorm) was administered after 24 hours at a 10 mg dosage for pain.
Intervention: GA group: Patients were anaesthetised with target-controlled infusion (TCI) using remifentanil (40 micrograms/ml) and propofol (10 mg/ml). Initial target plasma concentrations were computer-controlled and set as 5 ng/ml remifentanil and 5 micrograms/ml propofol. 0.6 mg/kg of rocuronium bromide was used to facilitate intubation, and ventilation of oxygen was kept at EtCO2 4.5 kPa. 0.5 mg glycopyrronium and 2.5 mg neostigmine were administered postoperatively, while 10mg oxycodone (OxyNorm) was provided intravenously 20 minutes before completion of surgery (n=60 randomized, 60 analyzed).
Comparison: SA group: Patients were given intrathecal (L4-L5) anaesthesia using a 25-G Quinke needle (Spinocan, B.Braun AG) containing isobaric bupivacaine (0.5%, 3 ml). A propofol infusion (10 mg/ml) was provided for light sedation during surgery. Oxygen was provided (2 l/min) (n=60 randomized, 58 analyzed)
Outcomes: Length of stay was the primary outcome, while other measurements of interest were time of discharge, pain through a visual analog scale (VAS) (at rest, with 45 degree knee flexion, with a straight knee, 45 degree hip flexion, and after walking for 5 m), rescue pain medication use, blood loss, length of stay in the post-operative care unit (PACU), dizziness through a VAS scale, blood pressure, post-operative nausea through a VAS scale, need for urinary catheterisation, and patient satisfaction.
Methods: RCT: Prospective
Time: Pain was assessed pre-operatively, upon arrival to the post-operative care unit (PACU), as well as at 2, 4, 6, and 10 hours. Dizziness was measured at postoperative 5, 8, and 14 hours. Blood loss was measured 24 hours after the surgery. Patient satisfaction was determined at 6 months postoperatively.
What were the important findings?
What should I remember most?
How will this affect the care of my patients?
The authors responsible for this critical appraisal and ACE Report indicate no potential conflicts of interest relating to the content in the original publication.
Dr. Frank Smith
January 27, 2016
Orthopaedic Surgeon - Canada
Astonishing! 95% at my hospital are done under Spinal and the patients who have experienced both always prefer spinal.