Study: Spinal, general anesthesia offer ‘reliable’ same-day discharge for outpatient TJA
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Key takeaways:
- Spinal and general anesthesia were associated with high rates of successful same-day discharge TJA.
- Patients who received general anesthesia had higher levels of pain and rates of nausea vs. spinal anesthesia.
Published results showed spinal and general anesthesia were associated with high rates of successful same-day discharge among patients who underwent outpatient total joint arthroplasty at a free-standing ASC.
Tyler E. Calkins, MD, and colleagues from the University of Tennessee Health Science Center performed a matched cohort study of data from 105 patients who underwent outpatient TJA with spinal anesthesia and 105 patients who underwent the procedure with general anesthesia from May 13, 2014, to Dec. 18, 2020, at a single ASC.
Outcomes included successful same-day discharge, time to discharge, pain, nausea and complication rates at 90 days postoperatively. Researchers also analyzed outcomes of patients who received mepivacaine vs. bupivacaine spinal anesthesia.
Calkins and colleagues found 100% of patients in the spinal anesthesia group had successful same-day discharge, while 98% of patients in the general anesthesia group had successful same-day discharge. Patients who received mepivacaine were discharged in 206 minutes, while patients who received general anesthesia were discharged in 227 minutes and patients who received bupivacaine were discharged in 291 minutes.
Researchers noted the general anesthesia group had higher levels of pain and higher rates of nausea compared with the spinal anesthesia group. They noted both groups had similar 90-day complications, readmissions and reoperations.
“While spinal anesthesia is the authors’ preferred regimen, these data support that general anesthesia is a reliable alternative for patients who are unable or choose not to undergo spinal anesthesia,” Calkins and colleagues wrote in the study.
Perspective
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Stavros G. Memtsoudis, MD, PhD, MBA
The debate regarding the preferred anesthetic technique for joint arthroplasty is as old as the specialty itself. There are numerous studies comparing general vs. neuraxial anesthesia and, while outcomes studied and conclusions vary, one can summarize the literature as follows: Most studies suggest a reduction in perioperative complications (including bleeding, pulmonary and infections) with neuraxial anesthesia when compared to general anesthesia. There are some studies suggesting equivalence, but virtually none show the superiority of general anesthesia. This has led experts, including the International Consensus Group for Anesthesia Related Outcomes After Surgery, to recommend neuraxial anesthesia for TJA whenever feasible. The underlying mechanism is likely related to the spinal anesthesia-induced sympathectomy, leading to avoidance of blood pressure spikes, better tissue perfusion and reduced systemic stress response, while avoiding the pitfalls of airway instrumentation and mechanical ventilation seen with a general approach. This does not mean that general anesthesia does not have a role to play or is unsafe as similar goals can be achieved when performed with expertise and attention to detail; however, a neuraxial anesthetic represents a “one stop shop” when seeking these results. Further, with the wider dissemination of peripheral nerve blocks for TJA, many benefits of spinal anesthesia can be achieved even for patients undergoing general anesthesia and have, therefore, been recommended in these settings. Like with any specialty of medicine, however, science and practice are constantly evolving and the evidence needs to be evaluated frequently to identify best practices.
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