Mepivacaine yielded early ambulation, more same-day discharge after THA
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Use of mepivacaine for spinal anesthesia during total hip arthroplasty led to earlier ambulation and a greater percentage of same-day discharge compared with hyperbaric and isobaric bupivacaine, according to results.
“Mepivacaine was superior to bupivacaine for early ambulation after total hip arthroplasty under spinal anesthesia,” Eric S. Schwenk, MD, told Healio Orthopedics.
Schwenk and colleagues randomly assigned 154 patients undergoing THA to receive mepivacaine (n=50), hyperbaric bupivacaine (n=53) or isobaric bupivacaine (n=51) for spinal anesthesia. The ability to ambulate between 3 hours and 3.5 hours after spinal placement was the study’s primary outcome.
“This timepoint was chosen based on previously established times from a study showing that mepivacaine spinals wore off in that window,” Schwenk said at the American Association of Hip and Knee Surgeons Annual Meeting. “This primary outcome was assessed by physical therapists who were blinded to group assignment.”
Mepivacaine tied to early ambulation
Researchers also considered return to motor and sensory function, postoperative pain, opioid consumption, urinary retention, transient neurological symptoms, intraoperative muscle tension, length of stay and 30-day readmission as secondary outcomes.
Schwenk noted 70% of patients in the mepivacaine group ambulated at 3 to 3.5 hours postoperatively compared with 37.7% of patients in the hyperbaric bupivacaine group and 17.6% of patients in the isobaric bupivacaine group. The odds of walking in the mepivacaine group vs. the hyperbaric bupivacaine group was 3.85 and the odds of walking in the mepivacaine group vs. the isobaric bupivacaine group was 10.8, he said.
“Almost double the percentage of patients were discharged the same day in the mepivacaine group vs. the other two groups,” Schwenk said.
Similar ambulation distance
Patients in the mepivacaine group had a shorter length of stay and earlier return of motor function vs. the other two groups, according to Schwenk. However, the three groups were not different based on initial ambulation distance, Tinetti score, urinary retention or dizziness, he said, noting all groups reported high patient satisfaction.
“In terms of pain outcomes, … early pain outcomes were a little bit worse for mepivacaine patients, but the differences disappeared later in the day and by postop day 1 they were gone,” Schwenk said.
He noted the groups had no differences regarding transient neurologic symptoms, defined as any back pain that was not present before surgery that went into the patient’s buttocks, thighs, hips or lower legs.
“The transient neurologic symptoms incidence was a little bit higher in our study than in some others, perhaps related to the definition, but there, nevertheless, was no difference between groups,” Schwenk said.
Assess anesthesia protocols
With use of standard ambulation assessment time and the ability to have all patients seen during a consistent time frame, the results of this study improved upon prior work, according to Schwenk. He noted while mepivacaine could be beneficial in outpatient THA programs when early ambulation is desired, such programs require a coordinated effort between anesthesiology, surgery and physical therapy.
“[In] future studies we should be looking at general vs. spinal general anesthesia using modern anesthesia protocols and short-acting spinal drugs and a combination of peripheral nerve blocks and multimodal analgesia to see which type of anesthesia truly is beneficial,” Schwenk said.
Reference:
Schwenk ES, et al. Anesthesiology. 2020;doi:10.1097/ALN.0000000000003480.
For more information:
Eric S. Schwenk, MD, can be reached at Sydney Kimmel Medical College at Thomas Jefferson University, 1025 Walnut St., #100, Philadelphia, PA 19107; email: eric.schwenk@jefferson.edu.
Perspective
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The evidence regarding mepivacaine is growing and this study corroborates its relative safety in terms of facilitating rapid recovery and same-day discharge after TJA. There are pros and cons to each of the agents used for single-shot spinal anesthesia in this study, so surgeons must continue to work with anesthesiologists to weigh the risks of urinary retention vs. transient neurologic symptoms when deciding what is best for their patients.
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Schwenk ES, et al. Paper 53. Presented at: American Association of Hip and Knee Surgeons Annual Meeting; Nov. 5-8, 2020; Dallas (hybrid meeting).
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