Abstract
Background
This study compared the efficacy and safety of 3 different anesthesia techniques used in total hip arthroplasty (THA).
Material/Methods
We allocated 198 patients preparing to undertake THA into 3 groups: general anesthesia group (GA group, n=66), caudal epidural anesthesia group (CEA group, n=66), and spinal-epidural anesthesia group (SEA group, n=66). We compared postoperative adverse effects occurring in patients of the 3 anesthesia groups. The Visual Analog Scale (VAS) score, Minimum Mental State Examination (MMSE) score, and β-amyloid (Aβ) expression were calculated to determine the effects of different anesthesia on the postoperative pain and cognitive dysfunction of patients.
Results
The CEA and SEA groups had lower rates of perioperative adverse effects than in the GA group. Patients in the GA group required significantly higher administration of analgesics after the surgery than those in CEA and SEA groups. Higher Aβ expression levels and VAS scores, as well as lower MMSE scores, were also seen in the GA group compared with the other 2 groups.
Conclusions
CEA and SEA were more effective than GA in THA, and CEA seemed to be a better anesthesia technique than SEA.
MeSH Keywords: Anesthesia, Epidural; Anesthesia, General; Anesthesia, Spinal; Arthroplasty, Replacement, Hip
Background
Total hip arthroplasty (THA) has become one of the most common surgical operations since 1960 and is regarded as a revolutionary technique significantly improving the outlook for patients with degenerative osteoarthritis, rheumatoid arthritis, proximal femoral fractures, or other damaged hip joints [1]. This technique replaces the dysfunctional joint surface with an artificial prosthesis so that severe pain can be alleviated and normal joint functions can be restored [2,3]. However, THA is usually associated with severe pain during the perioperative period, so it may not be ideal for older patients who often have higher risk of hypertension, renal dysfunction, or ischemic heart disease. As a result, researchers have begun to pursue an effective anesthesia technique to enhance the effectiveness of THA [4–6]. Various anaesthetic and analgesic approaches have been used in conjunction with THA; classical approaches include general anesthesia (GA), caudal epidural anesthesia (CEA), and spinal-epidural anesthesia (SEA) [7–10]. Many studies have suggested that neuraxial anesthesia (epidural or spinal anesthesia) is effective for improving perioperative outcomes, particularly among orthopedic patients [11]. GA has been considered the “gold standard” for the majority of hip procedures and is able to induce fast and thorough anesthesia effects in patients preparing to undergo surgeries [12,13]. However, more recently, regional anesthesia has attracted attention, as it has tremendous potential advantages over GA, allowing for administration to the affected area specifically. Moreover, regional anesthesia is associated with a reduced risk of severe complications such as deep venous thrombosis and surgical site infection [9,12,14]. The implementation of regional analgesia can be achieved through epidural, spinal, or combined approaches [15]. If regional analgesia is implemented in an epidural approach, pain-relieving drugs are injected into the epidural space through a catheter [16]. For spinal anesthesia, the drugs are injected directly into the cerebrospinal fluid around the nerves, taking less time to achieve the corresponding anesthesia effects [17]. There is also a combined technique that has been introduced into clinical practice, which uses a single spinal injection, which is further assisted by an epidural catheter so that pain relief can be achieved continuously [15,18,19]. Several reports have indicated that spinal-epidural anesthesia has superior effectiveness, and patients treated with this approach have lower risk of adverse outcomes compared with conventional regional analgesia techniques [15,20–22]. However, a comprehensive comparison of these anesthesia techniques for THA has not been carried out to date.
Multiple measurements have been established for assessing the effectiveness and safety of anesthesia techniques, including onset time of anesthesia, duration of anesthesia efficacy, analgesic dosage required, postoperative pain scores-Visual Analog Scale (VAS), length of hospital stay, and rate of adverse effects [4,5,23]. Apart from these, postoperative cognitive dysfunction (POCD) following anesthesia in conjunction with THA, a prevailing complication that may affect cognitive functions and trigger short-term memory loss [24–26], is also taken into consideration when assessing the efficacy of different anaesthetic methods.
The present study is the first to compare the effects of 3 anesthesia methods on perioperative outcomes during THA. Our results revealed that SEA and CEA were more appropriate than GA for patients undergoing THA. This research may provide clinicians with useful information when choosing the best anesthesia technique for patients undergoing THA.
Material and Methods
Patients
We enrolled a total of 198 patients (106 females and 92 males, with an average age of 67 years) preparing to undergo THA. Using a computer-generated permutation digits method, patients were randomly allocated into 3 groups: general anesthesia group (GA group, n=66), caudal epidural anesthesia group (CEA group, n=66), and spinal-epidural anesthesia (SEA group, n=66). All study procedures were agreed upon and approved by the Institutional Ethics Committee of Huadong Hospital Affiliated to Fudan University. Informed consent was obtained from patients prior to inclusion.
Inclusion and exclusion criteria
As recommended by the guidelines of the American Society of Anesthesiologists (ASA), patients with ASA I-III preparing to undergo arthroplasty between March 2013 and March 2015 were included. The enrolled patients had no history of nervous system or cardiac surgery, no history of mental disorder, no severely defective vision, and no neurological disorders.
We excluded all patients who refused to participate, as well as those with Mini-Mental State Examination (MMSE) score less than 23, with neurological disease or mental disorder, with long-term use of sedatives or anti-depressant, with history of alcohol consumption, with preoperative hypovolemia, with puncture site infection, with delirium or agitation, and those who could not be successfully anaesthetized within 15 min of drug injection.
Anesthesia and monitoring
Electrocardiogram (ECG), non-invasive arterial blood pressure, heart rate, and peripheral blood oxygen saturation (SpO2) levels were all monitored while patients were in the operating theater.
GA was induced by administration of Midazolam (0.1 mg/kg), propofol (1–1.5 mg/kg), fentanyl (2–4 μg/kg), and vecuronium bromide (0.1–0.15 mg/kg). The tidal volume was 8–10 mg/kg, and respiratory frequency was 10–12 times/min. The end-tidal CO2 partial pressure was also maintained within the range of 32 and 38 mmHg. Maintenance of anesthesia was performed with 6–8 mg/kg propofol infusion.
The sacral hiatus of patients in the CEA group was inspected when the operation position was changed to lateral decubitus position. A 22-gauge needle (Terumo, Japan) was used to continuously inject the anaesthetic (0.5% plain bupivacaine) into the epidural space. Negative aspiration technique was used to prevent intravascular insertion and accidental intrathecal injection.
In a seated position, SEA was performed using a needle-through-needle technique at L1–2 or L3–4 intervertebral disc space using an 18-gauge Tuohy needle (Perifix, Germany). Skin infiltration was achieved with 1% lidocaine. The dural puncturing was performed using a 27-gauge pencil point spinal needle. Once the cerebrospinal fluid aspiration was achieved, 2 ml 0.5% hyperbaric bupivacaine was injected. We then performed epidural injection of 10 ml 0.25% plain bupivacaine, 1 ml clonidine (2 μg/kg), and 1 ml fentanyl (25 μg).
Determination of sensory and motor blockade
Sensory blockade was assessed every 2 min within 30 min of epidural injection using a pinprick test. When the sensory blockade reached the dermatome of T10, the patients were considered ready for surgery.
Motor blockade was assessed every 5 min within 30 min after epidural injection, using the modified Bromage score (BS) [27]. BS0 is defined as full hip flexion; BS1 is defined as impaired hip flexion; BS2 is impaired hip; BS3 is unable to flex hip, and so on to complete motor block. Recovery from motor block was defined as time from epidural injection to BS0.
Hypotension is a fall of mean arterial blood pressure from the pre-surgery level or a systolic blood pressure lower than 100 mmHg. Once hypotension occurred, patients were treated with 5 mg inj. ephedrine. Bradycardia is the decline of heart rate below 50 beats/min, and if this occurred, patients were treated with 0.5 mg inj. atropine.
Pain assessment and management
Intraoperative and postoperative pain was assessed using the Visual Analog Scale (VAS). VAS score ranges from 0 (no pain) to 10 (worst pain possible). VAS was measured every 15 min intraoperatively and every 3 h postoperatively for the first 12 h, then 12 h afterwards by an anesthesiologist who was unaware of the patient grouping. All patients received injected acetaminophen (15 mg/kg) before the completion of surgery and every 6 h afterwards. After surgery, to patients with VAS >4, fentanyl was administered at 50 μg increments, whereas those with VAS <4 were given acetaminophen infusion [28,29].
Postoperative complication and cognition assessment
Postoperative adverse effects were recorded, including pulmonary embolism, pneumonia, cardiac infarction, hypertension, renal failure, blood transfusion, and mechanical ventilation.
POCD was estimated by Mini-Mental State Examination (MMSE) score. MMSE incorporates 30 questions equalling 30 points. POCD was diagnosed if the MMSE score was lower than 23.
β-amyloid (Aβ) expression
Aβ expression was detected using enzyme-linked immunosorbent assay (ELISA). We collected 5 ml fasting venous blood samples from patients at 1 day before surgery (T1), 1 day after surgery (T2), and 5 days after surgery (T3).
Statistical analysis
All statistical analyses were performed using SPSS 18.0 software (Chicago, IL, USA). Data are presented in the form of mean ± standard deviation (SD). One-way analysis of variance (ANOVA) or Kruskal-Wallis test was used to analyze between-group comparisons, whereas the chi-square test was used for assessing the differences of categorical variables between groups. P<0.05 was set as the threshold for statistical significance.
Results
Clinical characteristics
The clinical characteristics of all patients were compared among the 3 anesthesia groups. No significant difference in clinical characteristics, including sex, age, weight, height, body mass index (BMI), ASA physical status, preexisting diseases, preoperative diagnosis, and contralateral hip limitation, was identified among the 3 groups (Table 1).
Table 1.
Variable | GA (n=66) | CEA (n=66) | SEA (n=66) | P-value |
---|---|---|---|---|
Gender (F/M) | 37/29 | 34/32 | 35/31 | 0.868 |
Age (years) | 68±11 | 67±12 | 66±10 | 0.582 |
Weight (kg) | 70±11 | 69±9 | 70±11 | 0.815 |
Height (cm) | 163±8 | 165±9 | 166±9 | 0.132 |
BMI (kg/m2) | 23.2±3.3 | 23.4±3.9 | 23.0±2.7 | 0.800 |
ASA physical status | ||||
ASA I | 11 | 15 | 12 | 0.878 |
ASA II | 53 | 49 | 51 | |
ASA III | 2 | 2 | 1 | |
Preexisting diseases | ||||
Hypertension | 31 | 33 | 34 | 0.995 |
Coronary heart disease | 11 | 12 | 10 | |
Diabetes mellitus | 39 | 42 | 41 | |
Hyperlipidemia | 32 | 34 | 29 | |
Cardiopathy | 0 | 2 | 1 | |
Cerebrovascular disease | 9 | 11 | 6 | |
Renal failure | 0 | 0 | 0 | |
Liver failure | 1 | 1 | 1 | |
Preoperative diagnosis | ||||
Arthrosis | 43 | 45 | 49 | 0.745 |
Rheumatoid arthritis | 11 | 4 | 7 | |
Ankylosing spondylitis | 9 | 10 | 6 | |
Avascular necrosis | 3 | 7 | 4 | |
Limitation of the contralateral hip | ||||
Yes | 42 | 43 | 40 | 0.860 |
No | 24 | 23 | 26 |
Data are n or mean ±SD. GA – general anaesthesia; CEA – caudal epidural anaesthesia; SEA – spinal-epidural anaesthesia; F – female; M – male; BMI – body mass index; ASA – American Society of Anesthesiologists.
Perioperative outcomes
Intraoperative outcomes, including duration of surgery and anesthesia, time until maximal sensory blockade (S max), and motor blockade as well as the analgesic requirement after surgery, were compared among the 3 groups to determine their efficiency and efficacy in pain management (Table 2). CEA and SEA both demonstrated significantly shorter duration of surgery, faster motor blockade, and shorter duration of anesthesia than in the GA group. CEA patients showed significantly shorter time to S max than GA. Although the SEA group showed significantly longer surgery and anesthesia duration than in the CEA, the 2 groups did not differ in time to motor blockade or analgesic requirement. Patients in the GA group exhibited significantly higher analgesic consumption than those in the CEA or SEA groups, while patients in the CEA group consumed significantly less analgesic than those in the SEA group.
Table 2.
Variable | GA (n=66) | CEA (n=66) | SEA (n=66) |
---|---|---|---|
Duration of surgery (min) | 120.5±26.5 | 86.4±18.5* | 100.5±22.5*# |
Time to S max (min) | 18.2±2.6 | 12.5±1.8* | 15.4±2.2 |
Time to motor blockade (min) | 23.3±6.4 | 14.0±3.2* | 14.4±3.6* |
Total duration of anesthesia (min) | 207.5±16.2 | 56.3±13.3* | 48.3±11.8*# |
Analgesics requirement within 48 h after surgery (g) | 5.2±2.2 | 2.6±0.9 | 3.5±1.2 |
Data are n or mean ±SD. GA – general anaesthesia; CEA – caudal epidural anaesthesia; SEA – spinal-epidural anaesthesia; S max – maximal sensory blockade.
P<0.05 versus GA group,
P<0.05 versus CEA group.
Postoperative complication assessments
Postoperative adverse effects, including pulmonary embolism, pneumonia, cardiac infarction, hypertension, renal failure, blood transfusion, and mechanical ventilation, were identified and compared among treatment groups (Table 3). No significant differences were observed among the 3 groups.
Table 3.
Complications | GA% (n) | CEA% (n) | SEA% (n) | P value |
---|---|---|---|---|
Pulmonary embolism | 3.0 (2) | 0.0 (0) | 1.5 (1) | 0.9257 |
Pneumonia | 1.5 (1) | 0.0 (0) | 1.5 (1) | |
Renal failure | 1.5 (1) | 0.0 (0) | 0.0 (0) | |
Cardiac infarction | 3.0 (2) | 1.5 (1) | 3.0 (2) | |
Blood transfusion | 6.0 (4) | 3.0 (2) | 6.1 (4) | |
Mechanical ventilation | 3.0 (2) | 1.5 (1) | 0.0 (0) |
Data were presented as % (n). GA – general anaesthesia; CEA – caudal epidural anaesthesia; SEA – spinal-epidural anaesthesia.
VAS score
VAS scores were calculated within 24 h after surgery to evaluate pain intensity experienced by patients. Patients in the GA group had significantly higher VAS scores than those in the CEA or SEA groups, while those in the SEA group exhibited remarkably higher VAS scores than those in the CEA group at 3 h, 6 h and 24 h after surgery (Table 4).
Table 4.
Variable | GA (n=66) | CEA (n=66) | SEA (n=66) |
---|---|---|---|
3 h | 5.13±1.67 | 1.92±0.78* | 2.95±0.89*# |
6 h | 5.12±1.65 | 1.20±0.46* | 2.75±0.88*# |
9 h | 4.91±1.28 | 1.13±0.21* | 1.49±0.50* |
12 h | 3.86±1.32 | 1.16±0.28* | 1.34±0.48* |
24 h | 4.38±1.40 | 1.69±0.56* | 2.75±0.96*# |
Data are n or mean ±SD. GA – general anaesthesia; CEA – caudal epidural anaesthesia; SEA – spinal-epidural anaesthesia; VAS – Visual Analog Scale.
P<0.05 versus GA group;
P<0.05 versus CEA group.
MMSE score
We calculated the MMSE scores at different time points (T1, T2, and T3). The MMSE score generally decreased from T1 to T2 and increased from T2 to T3. GA group patients had remarkably lower MMSE scores than in group CEA at T2 and T3. The MMSE score of the CEA group was significantly higher than that of the SEA group at T2 and T3, especially at T2 (Table 5).
Table 5.
Variable | GA (n=66) | CEA (n=66) | SEA (n=66) |
---|---|---|---|
T1 (1 d before surgery) | 26.72±1.62 | 26.84±1.98 | 26.55±1.89 |
T2 (1 d after surgery) | 22.45±2.32 | 24.46±1.43* | 22.48±1.84# |
T3 (5 d after surgery) | 24.19±2.25 | 25.69±2.01* | 24.69±1.98# |
Data are presented as n or mean ±SD. GA – general anaesthesia; CEA – caudal epidural anaesthesia; SEA – spinal-epidural anaesthesia;
P<0.05 versus GA group,
P<0.05 versus CEA group.
Aβ expression
To further determine whether patients experienced cognitive deterioration after anesthesia, Aβ expression at different time points (T1, T2, and T3) was detected. Aβ expression peaked at T2. The GA group exhibited significantly higher Aβ expression compared with CEA and SEA groups at T2. No significant difference in the expression of Aβ was observed between the CEA and SEA groups at any time point (Table 6).
Table 6.
Variable | GA (n=66) | CEA (n=66) | SEA (n=66) |
---|---|---|---|
T1 (1 d before surgery) | 51.16±15.76 | 50.90±15.50 | 51.94±12.92 |
T2 (1 d after surgery) | 79.85±13.44 | 53.49±11.11* | 54.52±12.92* |
T3 (5 d after surgery) | 54.26±13.70 | 52.45±17.57 | 52.97±15.25 |
Data are presented as n or mean ±SD. GA – general anaesthesia; CEA – caudal epidural anaesthesia; SEA – spinal-epidural anaesthesia;
P<0.05 versus GA group.
Discussion
This study aimed to compare the efficacy, efficiency, and safety of 3 anesthesia techniques during THA. VAS score, MMSE score, and Aβ expression were compared among patients treated with different forms of anesthesia. Our results demonstrated that neuraxial anesthesia (CEA and SEA) performed better than GA and that CEA worked better than SEA.
Recently, researchers have become concerned about the safety of using anesthesia in surgeries because patients may encounter significant blood loss during total joint arthroplasty and this is associated with worse surgical rehabilitation and complications [30]. CEA is considered an effective technique for reducing the amount of blood loss, which further reduces the cost of blood transfusion [31]. Although in this study the duration of surgery did not differ significantly among the 3 groups, both CEA and SEA were linked with a decrease in the amount of blood transfusion and analgesics required, and the duration of anesthesia. Wakamatsu et al, on the other hand, found that higher perioperative blood loss amount and operative blood loss rate were observed in the SEA group compared with the GA group [32]. Barnett et al. reported that postoperative complications, including cardiac arrhythmias, DVT, genitourinary, myocardial infarction, and hematological and pulmonary signs, may significantly affect surgical outcomes [33,34]. A meta-analysis conducted by Mauermann et al. revealed that patients under neuraxial block had lower rates of postoperative nausea and vomiting complications resulting from THA [23]. Peripheral nerve blocks have also been proven effective in reducing complications from joint arthroplasties [35]. In our study, patients in the SEA and CEA groups had significantly fewer complications than the GA group. We also discovered that GA group patients were more prone to experience pulmonary infection, myocardial ischemia, and postoperative cognitive dysfunction (POCD), and SEA group patients were more prone to have postoperative complications than were CEA group patients. POCD is one of the most severe potential complications, including perception disorders, and it can be triggered by inappropriate anesthesia techniques, especially among the elderly [24]. POCD may affect short-term memory as well as other cognitive functions, including visual and verbal memory, attention, language comprehension, and concentration [36]. In our experiments, patients in the GA group had significantly lower MMSE scores at T2 and T3 than those in the CEA and SEA groups. SEA patients demonstrated significantly lower MMSE scores than CEA patients at every time point. Our results suggest that CEA has the least effect on postoperative cognition recovery from anesthesia. Consistent with our results, Wulf et al. showed that patients who underwent hip replacement surgery receiving CEA had stronger mental identification and coordination than those who received GA [37]. Shi et al. also found that patients undergoing hip replacement surgery receiving GA had lower MMSE scores than those receiving CEA [38].
Aβ is derived from amyloid precursor protein (APP), and elevated Aβ production is central in cognitive disorder diseases such as Alzheimer disease [39,40]. Nonetheless, POCD is a more subtle symptom after anesthesia and has also been proven to be closely associated with Aβ expression [38,41]. Its expression level in patients receiving GA was significantly higher at T2 than those receiving CEA or SEA, indicating that GA stimulated the Aβ production process, leading to higher risk of POCD occurrence. Similar results also have been found in a study conducted by Shi et al., in which the Aβ level increased in patients who experienced POCD after GA [38]. Anwer et al. discovered that GA presented a significantly higher risk for POCD occurrence than did epidural anesthesia in elderly patients. All the evidence suggests that GA, rather than CEA or SEA, induces the production of Aβ, which then stimulates POCD. However, Wiliams-Russo et al. found that GA and epidural anesthesia did not present significant differences in terms of POCD magnitude [26,39]. These discrepancies among studies may be due to differences in sample sizes, which can affect statistical and clinical significance. Therefore, larger study populations are needed to fully illustrate the significance.
In addition, effective pain management using analgesics is crucial in facilitating early mobilization, reducing hospital stay, and lowering medical costs associated with THA [42,43]. We demonstrated that patients in the GA group had significantly higher analgesics consumption than in the CEA and SEA groups, whereas patients in the CEA group consumed less analgesic than those in the SEA group. In addition, a significantly higher VAS score was found in the GA group than in the CEA group and SEA groups. Therefore, we suspect that CEA and SEA are more appropriate for postoperative analgesia. As suggested by Horlocker et al, peripheral neuraxial anesthesia, together with analgesia with the combination of opioid and non-opioid analgesic agents, can efficiently reduce pain intensity [7]. The corresponding reduction in pain intensity accompanied by a reduced morphine dose has been verified in a randomized controlled trial (RCT) [33]. Studies on the postoperative effects of anesthesia are contradictory. For instance, Harsten et al. recommended that GA be used in conjunction with THA since it had some role in reducing hospital stay and alleviating pain intensity [32].
Conclusions
This is the first published study comparing the effects of 3 anesthesia methods on perioperative outcomes during THA. Our results reveal that SEA and CEA were more appropriate than GA for patients undergoing THA. However, we only analyzed the Aβ level in blood samples, and there may be other molecules that influence POCD. Therefore, we recommend carrying out further research to discover how GA affects Aβ and its relationship with certain postoperative cognitive disorders. In conclusion, CEA and SEA led to superior post-surgery recovery, both physically and mentally, compared to GA, and CEA appears to be a better anesthesia technique than SEA.
Abbreviations
- THA
total hip arthroplasty
- GA
general anesthesia
- CEA
caudal epidural anesthesia
- SEA
spinal-epidural anesthesia
- POCD
postoperative cognitive dysfunction
- MMSE
Mini-Mental State Examination
- VAS
Visual Analog Scale
- ELISA
enzyme-linked immunosorbent assay
- Aβ
β-amyloid
- RCTs
Randomized Controlled Trial
Footnotes
Source of support: Departmental sources
Availability of data and materials
Patient data were collected in Huadong Hospital Affiliated to Fudan University.
Competing interests
We confirm that we have read BioMed Central’s guidance on competing interests. The authors declare that no competing interests exist.
References
- 1.Learmonth ID, Young C, Rorabeck C. The operation of the century: Total hip replacement. Lancet. 2007;370:1508–19. doi: 10.1016/S0140-6736(07)60457-7. [DOI] [PubMed] [Google Scholar]
- 2.Atchabahian A, Schwartz G, Hall CB, et al. Regional analgesia for improvement of long-term functional outcome after elective large joint replacement. Cochrane Database Syst Rev. 2015;8:CD010278. doi: 10.1002/14651858.CD010278.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Bozic KJ, Beringer D. Economic considerations in minimally invasive total joint arthroplasty. Clin Orthop Relat Res. 2007;463:20–25. doi: 10.1097/blo.0b013e3181492943. [DOI] [PubMed] [Google Scholar]
- 4.Kita T, Maki N, Song YS, et al. Caudal epidural anesthesia administered intraoperatively provides for effective postoperative analgesia after total hip arthroplasty. J Clin Anesth. 2007;19:204–8. doi: 10.1016/j.jclinane.2006.10.011. [DOI] [PubMed] [Google Scholar]
- 5.Peters CL, Shirley B, Erickson J. The effect of a new multimodal perioperative anesthetic regimen on postoperative pain, side effects, rehabilitation, and length of hospital stay after total joint arthroplasty. J Arthroplasty. 2006;21:132–38. doi: 10.1016/j.arth.2006.04.017. [DOI] [PubMed] [Google Scholar]
- 6.Jules-Elysee KM, Goon AK, Westrich GH, et al. Patient-controlled epidural analgesia or multimodal pain regimen with periarticular injection after total hip arthroplasty: A randomized, double-blind, placebo-controlled study. J Bone Joint Surg Am. 2015;97:789–98. doi: 10.2106/JBJS.N.00698. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Horlocker TT. Pain management in total joint arthroplasty: A historical review. Orthopedics. 2010;33:14–19. doi: 10.3928/01477447-20100722-65. [DOI] [PubMed] [Google Scholar]
- 8.Hu S, Zhang ZY, Hua YQ, et al. A comparison of regional and general anaesthesia for total replacement of the hip or knee: A meta-analysis. J Bone Joint Surg Br. 2009;91:935–42. doi: 10.1302/0301-620X.91B7.21538. [DOI] [PubMed] [Google Scholar]
- 9.Opperer M, Danninger T, Stundner O, Memtsoudis SG. Perioperative outcomes and type of anesthesia in hip surgical patients: An evidence based review. World J Orthop. 2014;5:336–43. doi: 10.5312/wjo.v5.i3.336. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000;321:1493. doi: 10.1136/bmj.321.7275.1493. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Memtsoudis SG, Rasul R, Suzuki S, et al. Does the impact of the type of anesthesia on outcomes differ by patient age and comorbidity burden? Reg Anesth Pain Med. 2014;39:112–19. doi: 10.1097/AAP.0000000000000055. [DOI] [PubMed] [Google Scholar]
- 12.Indelli PF, Grant SA, Nielsen K, Vail TP. Regional anesthesia in hip surgery. Clin Orthop Relat Res. 2005;441:250–55. doi: 10.1097/01.blo.0000192355.71966.8e. [DOI] [PubMed] [Google Scholar]
- 13.Basques BA, Toy JO, Bohl DD, et al. General compared with spinal anesthesia for total hip arthroplasty. J Bone Joint Surg Am. 2015;97:455–61. doi: 10.2106/JBJS.N.00662. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Chang CC, Lin HC, Lin HW. Anesthetic management and surgical site infections in total hip or knee replacement: A population-based study. Anesthesiology. 2010;113:279–84. doi: 10.1097/ALN.0b013e3181e2c1c3. [DOI] [PubMed] [Google Scholar]
- 15.Simmons SW, Taghizadeh N, Dennis AT, et al. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev. 2012;10:CD003401. doi: 10.1002/14651858.CD003401.pub3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Wong CA, Ratliff JT, Sullivan JT, et al. A randomized comparison of programmed intermittent epidural bolus with continuous epidural infusion for labor analgesia. Anesth Analg. 2006;102:904–9. doi: 10.1213/01.ane.0000197778.57615.1a. [DOI] [PubMed] [Google Scholar]
- 17.Kulkarni SV, Agarwal P, Nagraj K. To compare the outcome of minor anorectal surgeries under local anesthesia versus spinal anesthesia. Indian J Surg. 2014;76:343–49. doi: 10.1007/s12262-012-0693-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Vernis L, Duale C, Storme B, et al. Perispinal analgesia for labour followed by patient-controlled infusion with bupivacaine and sufentanil: Combined spinal-epidural vs. epidural analgesia alone. Eur J Anaesthesiol. 2004;21:186–92. doi: 10.1017/s0265021504003047. [DOI] [PubMed] [Google Scholar]
- 19.Pascual-Ramirez J, Haya J, Perez-Lopez FR, et al. Effect of combined spinal-epidural analgesia versus epidural analgesia on labor and delivery duration. Int J Gynaecol Obstet. 2011;114:246–50. doi: 10.1016/j.ijgo.2011.04.004. [DOI] [PubMed] [Google Scholar]
- 20.Yousef AA, Atef AM, Awais WM. Comparison of fentanyl versus meperidine as supplements to epidural clonidine-bupivacaine in patients with lower limb orthopedic surgery under combined spinal epidural anesthesia. BMC Anesthesiol. 2015;15:146. doi: 10.1186/s12871-015-0126-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Neuman MD, Rosenbaum PR, Ludwig JM, et al. Anesthesia technique, mortality, and length of stay after hip fracture surgery. JAMA. 2014;311:2508–17. doi: 10.1001/jama.2014.6499. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Singh RK, Saini AM, Goel N, Bisht D, Seth A. Major laparoscopic surgery under regional anesthesia: A prospective feasibility study. Med J Armed Forces India. 2015;71:126–31. doi: 10.1016/j.mjafi.2014.12.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip replacement: A meta-analysis. Anesth Analg. 2006;103:1018–25. doi: 10.1213/01.ane.0000237267.75543.59. [DOI] [PubMed] [Google Scholar]
- 24.Terrando N, Brzezinski M, Degos V, et al. Perioperative cognitive decline in the aging population. Mayo Clin Proc. 2011;86:885–93. doi: 10.4065/mcp.2011.0332. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Steinmetz J, Christensen KB, Lund T, et al. Long-term consequences of postoperative cognitive dysfunction. Anesthesiology. 2009;110:548–55. doi: 10.1097/ALN.0b013e318195b569. [DOI] [PubMed] [Google Scholar]
- 26.Coburn M, Fahlenkamp A, Zoremba N, Schaelte G. Postoperative cognitive dysfunction: Incidence and prophylaxis. Anaesthesist. 2010;59:177–84. doi: 10.1007/s00101-009-1657-2. quiz 185. [DOI] [PubMed] [Google Scholar]
- 27.Lanz E, Theiss D, Kellner G, et al. Assessment of motor blockade during epidural anesthesia. Anesth Analg. 1983;62:889–93. [PubMed] [Google Scholar]
- 28.Yousef AA, Amr YM. The effect of adding magnesium sulphate to epidural bupivacaine and fentanyl in elective caesarean section using combined spinal-epidural anaesthesia: A prospective double blind randomised study. Int J Obstet Anesth. 2010;19:401–4. doi: 10.1016/j.ijoa.2010.07.019. [DOI] [PubMed] [Google Scholar]
- 29.Loper KA, Ready LB, Downey M, et al. Epidural and intravenous fentanyl infusions are clinically equivalent after knee surgery. Anesth Analg. 1990;70:72–75. doi: 10.1213/00000539-199001000-00012. [DOI] [PubMed] [Google Scholar]
- 30.Sizer SC, Cherian JJ, Elmallah RD, et al. Predicting blood loss in total knee and hip arthroplasty. Orthop Clin North Am. 2015;46:445–59. doi: 10.1016/j.ocl.2015.06.002. [DOI] [PubMed] [Google Scholar]
- 31.Modig J. Beneficial effects on intraoperative and postoperative blood loss in total hip replacement when performed under lumbar epidural anesthesia. An explanatory study. Acta Chir Scand Suppl. 1989;550:95–100. discussion 100–3. [PubMed] [Google Scholar]
- 32.Wakamatsu M, Ono K, Katoh H, et al. [Effect of combined spinal and epidural anesthesia on blood loss during total hip replacement]. Masui. 1993;42:56–59. [in Japanese] [PubMed] [Google Scholar]
- 33.Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review. Br J Anaesth. 2009;103:335–45. doi: 10.1093/bja/aep208. [DOI] [PubMed] [Google Scholar]
- 34.Barnett SL, Peters DJ, Hamilton WG, et al. Is the anterior approach safe? Early complication rate associated with 5090 consecutive primary total hip arthroplasty procedures performed using the anterior approach. J Arthroplasty. 2016;31(10):2291–94. doi: 10.1016/j.arth.2015.07.008. [DOI] [PubMed] [Google Scholar]
- 35.Gabriel RA, Kaye AD, Jones MR, et al. Practice variations in anesthetic care and its effect on clinical outcomes for primary total hip arthroplasties. J Arthroplasty. 2016;31(4):918–22. doi: 10.1016/j.arth.2015.08.031. [DOI] [PubMed] [Google Scholar]
- 36.Yang C, Zhu B, Ding J, Wang ZG. Isoflurane anesthesia aggravates cognitive impairment in streptozotocin-induced diabetic rats. Int J Clin Exp Med. 2014;7:903–10. [PMC free article] [PubMed] [Google Scholar]
- 37.Wulf H, Biscoping J, Beland B, et al. Ropivacaine epidural anesthesia and analgesia versus general anesthesia and intravenous patient-controlled analgesia with morphine in the perioperative management of hip replacement. Ropivacaine Hip Replacement Multicenter Study Group. Anesth Analg. 1999;89:111–16. doi: 10.1097/00000539-199907000-00019. [DOI] [PubMed] [Google Scholar]
- 38.Shi HJ, Xue XH, Wang YL, et al. Effects of different anesthesia methods on cognitive dysfunction after hip replacement operation in elder patients. Int J Clin Exp Med. 2015;8:3883–88. [PMC free article] [PubMed] [Google Scholar]
- 39.Williams-Russo P, Sharrock NE, Mattis S, et al. Cognitive effects after epidural vs. general anesthesia in older adults. A randomized trial. JAMA. 1995;274:44–50. [PubMed] [Google Scholar]
- 40.Iversen LL, Mortishire-Smith RJ, Pollack SJ, Shearman MS. The toxicity in vitro of beta-amyloid protein. Biochem J. 1995;311(Pt 1):1–16. doi: 10.1042/bj3110001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Manukhina EB, Goryacheva AV, Barskov IV, et al. Prevention of neurodegenerative damage to the brain in rats in experimental Alzheimer’s disease by adaption to hypoxia. Neurosci Behav Physiol. 2010;40(7):737–43. doi: 10.1007/s11055-010-9320-6. [DOI] [PubMed] [Google Scholar]
- 42.Strassels SA, Chen C, Carr DB. Postoperative analgesia: Economics, resource use, and patient satisfaction in an urban teaching hospital. Anesth Analg. 2002;94:130–7. doi: 10.1097/00000539-200201000-00025. table of contents. [DOI] [PubMed] [Google Scholar]
- 43.Frater RA, Moores MA, Parry P, Hanning CD. Analgesia-induced respiratory depression: Comparison of meptazinol and morphine in the postoperative period. Br J Anaesth. 1989;63:260–65. doi: 10.1093/bja/63.3.260. [DOI] [PubMed] [Google Scholar]