Choosing the Right Anesthesia
The primary anesthesia options include:
- General
- General endotracheal anesthesia (GETA)
- Total intravenous anesthesia (TIVA)
- Neuraxial/Regional
- Spinal
- Epidural
- Lumbar plexus in total hip arthroscopy
- Femoral nerve in total knee arthroscopy
According to Bradbury, if you can control these 6 variables—pain, PONV (nausea or vomiting after surgery), cognition, muscle weakness, urinary retention and orthostasis within 4 hours post op—you will win. Your patients will feel better and will be safe.
He said, “There is some data out there that can help us drive decision. Research has found higher occurrence of nausea and vomiting after total hip arthroplasty using general versus spinal anesthesia—1.5-2x increase risk of nausea with general anesthesia. And I think we can all agree that perioperative IV steroid use is making a place for itself in total joint replacement surgery. Best available data shows that it alleviates pain, alleviates nausea and there is no change in risk for PJI (periprosthetic joint infection).”
For Bradbury, cognition is his biggest pet peeve. He pointed to a study, “The Influence of Anesthesia and Pain Management on Cognition Dysfunction after Joint Arthroplasty” published online in Clinical Orthopaedics and Related Research in 2014 found that cognition dysfunction is more common with GETA in first week.
The researchers’ recommendations for using GETA is to optimize the depth of GETA, use non-opioid pain management and oral narcotics whenever possible. They also advise against the use of intravenous morphine and meperidine.
Spinal vs General
He said, “If you go to the recovery room, you can tell who has had a general, who has had a spinal. The spinal folks are sitting up and smiling, drinking ginger ale. While the general anesthetics are generally drooling over themselves or throwing up in a bucket. That has been my general experience. I am a big fan of being cognitive after surgery and this study supports that notion,” Bradbury said.
Orthostatic intolerance during early mobilization after fast-tracked hip arthroplasty is another important variable according to Bradbury.
This dangerous condition occurs when a patient experiences cerebral hypoperfusion upon standing. Symptoms include dizziness, nausea, blurred vision, diaphoresis and syncope.
Orthostatic intolerance during early mobilization after fast-tracked hip arthroplasty is unfortunately very common, 40% within 6 hours post op and 20% within 24 hours post op. It is associated with impaired cardiovascular orthostatic response; however, not associated with hemoglobin or opioid therapy so using orthostasis as an indicator for transfusion is probably a poor practice, according to Bradbury.
He said that while the precise pathophysiological mechanism is unknown it does appear to involve impaired reflex vasoconstriction and autoregulation of cerebral perfusion.
