The Impact of Neuraxial Versus General Anesthesia on the Incidence of Postoperative Surgical Site Infections Following Knee or Hip Arthroplasty

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Abstract

Recent studies have yielded conflicting results on the association between anesthesia technique and incidence of postoperative surgical site infections (SSIs) after knee arthroplasty (KA) and hip arthroplasty (HA). Our group conducted a meta-analysis of all available studies to clarify this potential association.

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Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees.

Maria Inacio, Elizabeth Paxton, R Namba (2013)

Deep surgical site infection following total knee arthroplasty is a devastating complication. Patient and surgical risk factors for this complication have not been thoroughly examined. The purpose of this study was to evaluate risk factors associated with deep surgical site infection following total knee arthroplasty in a large U.S. integrated health-care system. A retrospective review of a prospectively followed cohort of primary total knee arthroplasties recorded in a total joint replacement registry from 2001 to 2009 was conducted. Records were screened for deep surgical site infection with use of a validated algorithm, and the results were adjudicated by chart review. Patient factors, surgical factors, and surgeon and hospital characteristics were identified with use of the total joint replacement registry. Cox regression models were used to assess risk factors associated with deep surgical site infection. A total of 56,216 total knee arthroplasties were identified; 63.0% were done in women, the average age of the patients was 67.4 years (standard deviation [SD] = 9.6), and the average body mass index (BMI) was 32 kg/m2 (SD = 6). The incidence of deep surgical site infection was 0.72% (404/56,216). In a fully adjusted model, patient factors associated with deep surgical site infection included a BMI of ≥35 (hazard ratio [HR] = 1.47), diabetes mellitus (HR = 1.28), male sex (HR = 1.89), an American Society of Anesthesiologists (ASA) score of ≥3 (HR = 1.65), a diagnosis of osteonecrosis (HR = 3.65), and a diagnosis of posttraumatic arthritis (HR = 3.23). Hispanic race was protective (HR = 0.69). Protective surgical factors included use of antibiotic irrigation (HR = 0.67), a bilateral procedure (HR = 0.51), and a lower annual hospital volume (HR = 0.33). Surgical risk factors included quadriceps-release exposure (HR = 4.76) and the use of antibiotic-laden cement (HR = 1.53). In a subanalysis, operative time was a risk factor, with a 9% increased risk per fifteen-minute increment. Use of a comprehensive infection surveillance system, combined with a total joint replacement registry, identified patient and surgical factors associated with infection following total knee arthroplasty in a large sample. High-risk patients should be counseled, and modifiable clinical conditions should be optimized. Use of antibiotic irrigation should be encouraged, but antibiotic-laden cement may not be useful. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty.

Andrew Pugely, Christopher Martin, Yubo Gao … (2013)

Spinal anesthesia has been associated with lower postoperative rates of deep-vein thrombosis, a shorter operative time, and less blood loss when compared with general anesthesia. The purpose of the present study was to identify differences in thirty-day perioperative morbidity and mortality between anesthesia choices among patients undergoing total knee arthroplasty.

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A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a meta-analysis.

William Mauermann, Rebecca A. Shilling, Zhiyi Zuo (2006)

A recent meta-analysis showed that compared with general anesthesia (GA), neuraxial block reduced many serious complications in patients undergoing various types of surgeries. It is not known whether this finding from studying heterogeneous patient groups is applicable to a particular surgical patient population. We performed the present meta-analysis to determine whether anesthesia choice affected the outcome after elective total hip replacement (THR). Medline (1966 to August 2005), MD Consult (1966 to August 2005), BIOSIS (1969 to August 2005), and EMBASE (1969 to August 2005) databases were searched. Randomized and quasi randomized studies comparing GA and neuraxial (spinal or epidural) block for elective THR were included in this analysis. Ten independent trials, involving 330 patients under GA and 348 patients under neuraxial block, were identified and analyzed. Pooled results from five trials showed that neuraxial block significantly decreased the incidence of radiographically diagnosed deep venous thrombosis or pulmonary embolism. The odds ratio (OR) for deep venous thrombosis was 0.27 with 95% confidence interval (CI) 0.17-0.42. The OR for pulmonary embolism was 0.26 with 95% CI 0.12-0.56. Neuraxial block also decreased the operative time by 7.1 min/case (95% CI 2.3-11.9 min) and intraoperative blood loss by 275 mL/case (95% CI 180-371 mL). Data from three trials showed that patients under neuraxial block for THR were less likely to require blood transfusion than were patients under GA (21/177 = 12% vs 62/188 = 33% of patients transfused, P < 0.001 by z-test). The OR for this comparison was 0.26. However, the CIs were wide and compatible with both no effect and a nine-tenths reduction (95% CI 0.06-1.05). Patients undergoing elective THR under neuraxial anesthesia seem to have better outcomes than those under GA.

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Journal

Title: Regional Anesthesia and Pain Medicine

Abbreviated Title: Regional Anesthesia and Pain Medicine

Publisher: Ovid Technologies (Wolters Kluwer Health)

ISSN (Print): 1098-7339

Publication date Created: 2016

Publication date (Print): 2016

Volume: 41

Issue: 5

Pages: 555-563

Article

DOI: 10.1097/AAP.0000000000000437

PubMed ID: 27380106

SO-VID: b066b428-f6c0-4d9c-919c-67e42f61225a

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The Impact of Neuraxial Versus General Anesthesia on the Incidence of Postoperative Surgical Site Infections Following Knee or Hip Arthroplasty : A Meta-Analysis

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Most cited references 31

Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees.

Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty.

A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a meta-analysis.

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