Letters to the Editors / The Journal of Arthroplasty 31 (2016) 548–558
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Letters to the Editors Epidural Anesthesia and Perioperative Hypotension
In a retrospective study, Patel and colleagues [1] claimed that peripheral nerve blocks (PNB) were safe and effective for same day bilateral total knee arthroplasty (TKA) with a significant decrease in perioperative hypotension compared to epidural anesthesia, and that epidural patients required more blood transfusions and greater volumes of fluids. Although the paper did not provide the reasons for hypotension and the measures how to prevent and treat it, we think it is inappropriate to meet the normal blood pressure (BP) with only more fluids and blood transfusions and that as such doctors would have to consider more options. Perioperative hypotension is more likely to happen under epidural anesthesia, especially general anesthesia combined with epidural anesthesia [2]. The primary reason for this hypotension may be arterial vasodilation because of residual effects of anesthesia, but not pre-load deficiency or myocardial depression. It is certainly reasonable to support hypotension with a vasopressor (such as phenylephrine). Excess fluid or inotropic therapy is inappropriate, or even harmful for those patients soon after bilateral TKA. Because excess fluid would dilute the blood and reduce the hemoglobin concentration, thereby increase the possibility of iatrogenic blood transfusion. So the epidural group in their study required more blood transfusions and greater volumes of hespan and crystalloid which would cause excessive pre-load once the residual effects of anesthesia gradually disappeared. While inotropic therapy would cause the relatively greater loss of parasympathetic activity which would increase perioperative morbidity [3]. On the other hand, we do not think it is appropriate for all patients in the epidural group to receive laryngeal mask anesthesia since epidural analgesia can provide adequate analgesia for bilateral TKA. IV sedation applying a small dose of propofol or dexmedetomidine might be a better choice. Yongxin Liang, MD Shiduan Wang, MD ⁎ Department of Anesthesiology The Affiliated Hospital of Qingdao University Qingdao, China ⁎ Reprint requests: Shiduan Wang, MD, Department of Anesthesiology The Affiliated Hospital of Qingdao University, 16 Jiangsu Road Qingdao, China, 276000
2. Liang Y, Chu H, Zhen H, et al. A prospective randomized study of intraoperative thoracic epidural analgesia in off-pump coronary artery bypass surgery. J Anesth 2012;26:393. 3. Botto F, Alonso-Coello P, Chan MT, et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology 2014;120:564.
Epidural Anesthesia and Perioperative Hypotension
In Reply: The authors appreciate the important observation that excess fluid or inotropic therapy following same day bilateral total knee arthroplasty performed under epidural anesthesia may be harmful to this group of patients. For many years, these patients were kept in the PACU for close monitoring with particular attention to avoiding fluid overuse and minimizing inotropic support. In our study, the primary endpoint was postoperative hypotension and secondary outcomes were fluid volume, transfusion, or other measures such as pruritis. We agree that perioperative hypotension is more likely to occur under epidural anesthesia than with the use of peripheral nerve block and this is the main conclusion of our study. The authors acknowledge that this retrospective cohort study lacks the methodologic rigor of an RCT; the study was performed as a pilot in anticipation of such a prospective investigation. Based on our observations, we were not ethically able to initiate that study given the clear differences in post-operative course with peripheral nerve block patients experiencing a dramatically more stable course in the PACU and immediate post-operative phase of their care.
Courtland G. Lewis, MD Connecticut Joint Replacement Institute, Farmington, Connecticut Reprint requests: Courtland G. Lewis, MD, Orthopaedics 499 Farmington Avenue, Suite 300, Farmington, CT 06032 http://dx.doi.org/10.1016/j.arth.2015.06.042
http://dx.doi.org/10.1016/j.arth.2015.06.023 References 1. Patel N, Solovyova O, Matthews G, et al. Safety and efficacy of continuous femoral nerve catheter with single shot sciatic nerve block vs epidural catheter anesthesia for same-Day bilateral total knee arthroplasty. J Arthroplasty 2015;30:330. No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.06.023.
0883-5403/© 2015 Elsevier Inc. All rights reserved.
No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.06.042.
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Letters to the Editors Epidural Anesthesia and Perioperative Hypotension
In a retrospective study, Patel and colleagues [1] claimed that peripheral nerve blocks (PNB) were safe and effective for same day bilateral total knee arthroplasty (TKA) with a significant decrease in perioperative hypotension compared to epidural anesthesia, and that epidural patients required more blood transfusions and greater volumes of fluids. Although the paper did not provide the reasons for hypotension and the measures how to prevent and treat it, we think it is inappropriate to meet the normal blood pressure (BP) with only more fluids and blood transfusions and that as such doctors would have to consider more options. Perioperative hypotension is more likely to happen under epidural anesthesia, especially general anesthesia combined with epidural anesthesia [2]. The primary reason for this hypotension may be arterial vasodilation because of residual effects of anesthesia, but not pre-load deficiency or myocardial depression. It is certainly reasonable to support hypotension with a vasopressor (such as phenylephrine). Excess fluid or inotropic therapy is inappropriate, or even harmful for those patients soon after bilateral TKA. Because excess fluid would dilute the blood and reduce the hemoglobin concentration, thereby increase the possibility of iatrogenic blood transfusion. So the epidural group in their study required more blood transfusions and greater volumes of hespan and crystalloid which would cause excessive pre-load once the residual effects of anesthesia gradually disappeared. While inotropic therapy would cause the relatively greater loss of parasympathetic activity which would increase perioperative morbidity [3]. On the other hand, we do not think it is appropriate for all patients in the epidural group to receive laryngeal mask anesthesia since epidural analgesia can provide adequate analgesia for bilateral TKA. IV sedation applying a small dose of propofol or dexmedetomidine might be a better choice. Yongxin Liang, MD Shiduan Wang, MD ⁎ Department of Anesthesiology The Affiliated Hospital of Qingdao University Qingdao, China ⁎ Reprint requests: Shiduan Wang, MD, Department of Anesthesiology The Affiliated Hospital of Qingdao University, 16 Jiangsu Road Qingdao, China, 276000
2. Liang Y, Chu H, Zhen H, et al. A prospective randomized study of intraoperative thoracic epidural analgesia in off-pump coronary artery bypass surgery. J Anesth 2012;26:393. 3. Botto F, Alonso-Coello P, Chan MT, et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology 2014;120:564.
Epidural Anesthesia and Perioperative Hypotension
In Reply: The authors appreciate the important observation that excess fluid or inotropic therapy following same day bilateral total knee arthroplasty performed under epidural anesthesia may be harmful to this group of patients. For many years, these patients were kept in the PACU for close monitoring with particular attention to avoiding fluid overuse and minimizing inotropic support. In our study, the primary endpoint was postoperative hypotension and secondary outcomes were fluid volume, transfusion, or other measures such as pruritis. We agree that perioperative hypotension is more likely to occur under epidural anesthesia than with the use of peripheral nerve block and this is the main conclusion of our study. The authors acknowledge that this retrospective cohort study lacks the methodologic rigor of an RCT; the study was performed as a pilot in anticipation of such a prospective investigation. Based on our observations, we were not ethically able to initiate that study given the clear differences in post-operative course with peripheral nerve block patients experiencing a dramatically more stable course in the PACU and immediate post-operative phase of their care.
Courtland G. Lewis, MD Connecticut Joint Replacement Institute, Farmington, Connecticut Reprint requests: Courtland G. Lewis, MD, Orthopaedics 499 Farmington Avenue, Suite 300, Farmington, CT 06032 http://dx.doi.org/10.1016/j.arth.2015.06.042
http://dx.doi.org/10.1016/j.arth.2015.06.023 References 1. Patel N, Solovyova O, Matthews G, et al. Safety and efficacy of continuous femoral nerve catheter with single shot sciatic nerve block vs epidural catheter anesthesia for same-Day bilateral total knee arthroplasty. J Arthroplasty 2015;30:330. No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.06.023.
0883-5403/© 2015 Elsevier Inc. All rights reserved.
No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.06.042.
