LETTERS TO THE EDITOR
function was better and patients requested a change in the method of anaesthesia less often. However, patients in the spinal anaesthesia group fulfilled discharge criteria earlier. We were astonished about the conclusion. General anaesthesia resulted in a more favourable recovery, but the outcome after surgery was not mentioned. Morbidity and mortality were not studied in a controlled manner; there was only one interview via phone 6 months after surgery. This interview consisted of two questions, one about the experience of the anaesthesia and one about the type of anaesthesia if a total hip replacement surgery would be necessary again. Rodgers et al. analysed 141 trials with 9559 patients in their meta-analysis.2 They recommended a more widespread use of neuraxial blockade because mortality and morbidity were significantly reduced. Mortality was reduced by one third in patients with epidural or spinal anaesthesia. Moreover, serious complications like deep vein thrombosis and pulmonary embolism were reduced. The recovery profile in the first 24 h is important for the patient′s satisfaction. However, serious complications and mortality are more important. We know, that orthopaedic patients have a high risk to suffer from deep vein thrombosis; therefore, spinal or epidural anaesthesia are the preferable techniques.2 We think that the article should mention the potential benefit of neuraxial blockades. Especially patients with comorbidities may benefit from a neuraxial blockade concerning outcome after operation. Anaesthetists might change their recommendation concerning the type of anaesthesia (general anaesthesia vs. spinal anaesthesia) for the patients after reading the article. The results of the study are interesting because they show a shift towards better tolerance of general anaesthesia if performed as a total intravenous anaesthesia. We conducted a very similar study nearly 15 years ago.3 We performed general anaesthesia as a balanced anaesthesia. Many complications after surgery were similar in both groups, nausea, too; in the study by Harsten et al. nausea was reduced. References 1. Harsten A, Kehlet H, Ljung P, Toksvig-Larsen S. Total intravenous general anaesthesia vs. spinal
anaesthesia for total hip arthroplasty: a randomised, controlled trial. Acta Anaesthesiol Scand 2015; 59: 298–309. 2. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 32: 1–12. 3. Stober HD, Mencke T. General anesthesia or spinal anesthesia for hip prosthesis replacement? Studies of acceptance of both procedures by patients. Anaesthesiol Reanim 1999; 24: 151–6.
T. Mencke and S. Soltész
Total intravenous general anaesthesia vs. spinal anaesthesia for total hip arthroplasty Correspondence A. Harsten, Department of Anaesthesiology, Hässleholm Hospital, Box 351, 281 25 Hässleholm, Sweden E-mail: [email protected] Conflicts of interest None. Funding None. doi: 10.1111/aas.12495
Sir, We thank Dr Mencke and Dr Soltéz for their interesting comments about our study.1 Discharge from the ward (i.e. fulfilling the discharge criteria) was achieved earlier in the general anaesthesia group compared with the spinal anaesthesia group. However, discharge from postoperative care unit was achieved earlier in the spinal anaesthesia group. This could possibly be explained by the fact that we did not use local infiltration analgesia since it has been shown that it has no or limited effect in total hip arthroplasty surgery.2 As clearly stated in the discussion section, our study did not include serious adverse events or mortality. In order to do this in a prospective randomised trial, we would have to include a significantly larger study population. Furthermore, we do mention the study by Rodgers et al.3 pointing out that this review was based on studies performed 15–30 years ago. Acta Anaesthesiologica Scandinavica 59 (2015) 541–543
542
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© 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
LETTERS TO THE EDITOR
The scientific literature contains numerous studies showing no difference in mortality between general and regional anaesthesia.4–6 In the MASTER5 study, there were no differences in mortality, and the POISE6 trial it was shown that patients at high risk of cardiovascular morbidity, regional anaesthesia was associated with an increased risk of adverse outcome. Thromboembolic complications continue to be a problem. However, considering that the fast track technique has significantly reduced the length of hospital stay and increased early mobilisation one might wonder if it hasn’t also reduced the risk of deep venous thrombosis or pulmonary embolism.7 References 1. Harsten A, Kehlet H, Ljung P, Toksvig-Larsen S. Total intravenous general anaesthesia vs. spinal anaesthesia for total hip arthroplasty: a randomised, controlled trial. Acta Anaesthesiol Scand 2015; 59: 298–309. 2. Lunn TH, Husted H, Solgaard S, Kristensen BB, Otte KS, Kjersgaars AG, Gaarn-Larsen L, Kehlet H. Intraoperative local infiltration analgesia for early analgesia after total hip arthroplasty: a randomized, double-blind, placebo-controlled trial. Reg Anesth Pain Med 2001; 36: 424–9.
3. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321: 1–12. 4. Kettner S, Willschke H, Marhofer P. Does regional anaesthesia really improve outcome? Br J Anaesth 2011; 107: i90–5. 5. Rigg JR, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW, Collins KS, MASTER Anaethesia Trial Study Group. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359: 1276–82. 6. Leslie K, Myles P, Devereaux P, Williamson E, Rao-Melancini P, Forbes A, Xu S, Foex P, Pogue J, Arrieta M, Bryson G, Paul J, Paech M, Merchant R, Choi P, Badner N, Peyton P, Sear J, Yang H. Neuraxial block, death and serious cardiovascular morbidity in the POISE trial. Br J Anaesth 2013; 111: 382–90. 7. Jørgensen CC, Jacobsen MK, Soeballe K, Hansen TB, Husted H, Kjærsgaard-Andersen P, Hansen LT, Laursen MB, Kehlet H. Thromboprofylaxis only during hospitalisation in fast-track hip and knee arthroplasty, a prospective cohort study. BMJ Open 2013; 3: e003965. doi: 10.1136/bmjopen-2013-003965.
A. Harsten, H. Kehlet, P. Ljung and S. Toksvig-Larsen
Acta Anaesthesiologica Scandinavica 59 (2015) 541–543 © 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
543
Copyright of Acta Anaesthesiologica Scandinavica is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
function was better and patients requested a change in the method of anaesthesia less often. However, patients in the spinal anaesthesia group fulfilled discharge criteria earlier. We were astonished about the conclusion. General anaesthesia resulted in a more favourable recovery, but the outcome after surgery was not mentioned. Morbidity and mortality were not studied in a controlled manner; there was only one interview via phone 6 months after surgery. This interview consisted of two questions, one about the experience of the anaesthesia and one about the type of anaesthesia if a total hip replacement surgery would be necessary again. Rodgers et al. analysed 141 trials with 9559 patients in their meta-analysis.2 They recommended a more widespread use of neuraxial blockade because mortality and morbidity were significantly reduced. Mortality was reduced by one third in patients with epidural or spinal anaesthesia. Moreover, serious complications like deep vein thrombosis and pulmonary embolism were reduced. The recovery profile in the first 24 h is important for the patient′s satisfaction. However, serious complications and mortality are more important. We know, that orthopaedic patients have a high risk to suffer from deep vein thrombosis; therefore, spinal or epidural anaesthesia are the preferable techniques.2 We think that the article should mention the potential benefit of neuraxial blockades. Especially patients with comorbidities may benefit from a neuraxial blockade concerning outcome after operation. Anaesthetists might change their recommendation concerning the type of anaesthesia (general anaesthesia vs. spinal anaesthesia) for the patients after reading the article. The results of the study are interesting because they show a shift towards better tolerance of general anaesthesia if performed as a total intravenous anaesthesia. We conducted a very similar study nearly 15 years ago.3 We performed general anaesthesia as a balanced anaesthesia. Many complications after surgery were similar in both groups, nausea, too; in the study by Harsten et al. nausea was reduced. References 1. Harsten A, Kehlet H, Ljung P, Toksvig-Larsen S. Total intravenous general anaesthesia vs. spinal
anaesthesia for total hip arthroplasty: a randomised, controlled trial. Acta Anaesthesiol Scand 2015; 59: 298–309. 2. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 32: 1–12. 3. Stober HD, Mencke T. General anesthesia or spinal anesthesia for hip prosthesis replacement? Studies of acceptance of both procedures by patients. Anaesthesiol Reanim 1999; 24: 151–6.
T. Mencke and S. Soltész
Total intravenous general anaesthesia vs. spinal anaesthesia for total hip arthroplasty Correspondence A. Harsten, Department of Anaesthesiology, Hässleholm Hospital, Box 351, 281 25 Hässleholm, Sweden E-mail: [email protected] Conflicts of interest None. Funding None. doi: 10.1111/aas.12495
Sir, We thank Dr Mencke and Dr Soltéz for their interesting comments about our study.1 Discharge from the ward (i.e. fulfilling the discharge criteria) was achieved earlier in the general anaesthesia group compared with the spinal anaesthesia group. However, discharge from postoperative care unit was achieved earlier in the spinal anaesthesia group. This could possibly be explained by the fact that we did not use local infiltration analgesia since it has been shown that it has no or limited effect in total hip arthroplasty surgery.2 As clearly stated in the discussion section, our study did not include serious adverse events or mortality. In order to do this in a prospective randomised trial, we would have to include a significantly larger study population. Furthermore, we do mention the study by Rodgers et al.3 pointing out that this review was based on studies performed 15–30 years ago. Acta Anaesthesiologica Scandinavica 59 (2015) 541–543
542
bs_bs_banner
© 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
LETTERS TO THE EDITOR
The scientific literature contains numerous studies showing no difference in mortality between general and regional anaesthesia.4–6 In the MASTER5 study, there were no differences in mortality, and the POISE6 trial it was shown that patients at high risk of cardiovascular morbidity, regional anaesthesia was associated with an increased risk of adverse outcome. Thromboembolic complications continue to be a problem. However, considering that the fast track technique has significantly reduced the length of hospital stay and increased early mobilisation one might wonder if it hasn’t also reduced the risk of deep venous thrombosis or pulmonary embolism.7 References 1. Harsten A, Kehlet H, Ljung P, Toksvig-Larsen S. Total intravenous general anaesthesia vs. spinal anaesthesia for total hip arthroplasty: a randomised, controlled trial. Acta Anaesthesiol Scand 2015; 59: 298–309. 2. Lunn TH, Husted H, Solgaard S, Kristensen BB, Otte KS, Kjersgaars AG, Gaarn-Larsen L, Kehlet H. Intraoperative local infiltration analgesia for early analgesia after total hip arthroplasty: a randomized, double-blind, placebo-controlled trial. Reg Anesth Pain Med 2001; 36: 424–9.
3. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321: 1–12. 4. Kettner S, Willschke H, Marhofer P. Does regional anaesthesia really improve outcome? Br J Anaesth 2011; 107: i90–5. 5. Rigg JR, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW, Collins KS, MASTER Anaethesia Trial Study Group. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359: 1276–82. 6. Leslie K, Myles P, Devereaux P, Williamson E, Rao-Melancini P, Forbes A, Xu S, Foex P, Pogue J, Arrieta M, Bryson G, Paul J, Paech M, Merchant R, Choi P, Badner N, Peyton P, Sear J, Yang H. Neuraxial block, death and serious cardiovascular morbidity in the POISE trial. Br J Anaesth 2013; 111: 382–90. 7. Jørgensen CC, Jacobsen MK, Soeballe K, Hansen TB, Husted H, Kjærsgaard-Andersen P, Hansen LT, Laursen MB, Kehlet H. Thromboprofylaxis only during hospitalisation in fast-track hip and knee arthroplasty, a prospective cohort study. BMJ Open 2013; 3: e003965. doi: 10.1136/bmjopen-2013-003965.
A. Harsten, H. Kehlet, P. Ljung and S. Toksvig-Larsen
Acta Anaesthesiologica Scandinavica 59 (2015) 541–543 © 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
543
Copyright of Acta Anaesthesiologica Scandinavica is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
