Hypotensive Epidural Anesthesia in Patients With Aortic Stenosis Undergoing Total Hip Replacement

Ho, Michael; Beathe, Jonathan C.; Sharrock, Nigel E.

doi:10.1016/j.rapm.2007.09.008

Cited by 17 publications

(13 citation statements)

References 16 publications

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“…These findings concur with previous studies examining these risks in both maxillofacial and arthroplasty surgery [2,20]. Studies also show that hypotensive epidural anesthesia can be safely used in higher risk patients, including the elderly, and patients with hypertension, ischemic heart disease, or chronic renal impairment [7,17]. Lubrano et al [11] demonstrated a transient tubular dysfunction after induced hypotension with propofol and remifentanil (without concurrent adrenaline); however, a clear link to permanent renal dysfunction has not been demonstrated [17].…”

Section: Discussionsupporting

confidence: 82%

“…The technique, which involves a reduction in blood pressure while maintaining flow through stabilization of cardiac output, has demonstrated efficacy in lower limb orthopaedic surgery [7,[17][18][19][20]22], where it has been shown to reduce blood loss and transfusion reaction. Hypotensive epidural anesthesia provides sympathetic blockade by means of a high epidural anesthetic and sustained cardiac output by means of an adrenaline infusion.…”

Section: Introductionmentioning

confidence: 99%

“…Tachycardia from intraoperative hypovolemia maybe masked with the technique and careful monitoring of blood loss during surgery is crucial. Despite these risks, studies have shown no increased incidence of end-organ damage after hypotensive epidural anesthesia, even in patients with existing comorbidities [7,11,17].…”

Section: Introductionmentioning

confidence: 99%

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Hypotensive Epidural Anesthesia Reduces Blood Loss in Pelvic and Sacral Bone Tumor Resections

Freeman

Thorne

Gaston

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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Background Resection of pelvic and sacral tumors can cause severe blood loss, complications, and even postoperative death. Hypotensive epidural anesthesia has been used to mitigate blood loss after elective arthroplasty, but to our knowledge, it has not been studied as an approach that might make resection of pelvic and sacral tumors safer. Questions/purposes The purposes of this study were (1) to compare the blood loss and blood product use for patients undergoing pelvic and sacral tumor surgery under standard anesthesia or hypotensive epidural anesthesia; (2) to assess the frequency of end-organ damage with the two techniques; and (3) to compare 90-day mortality between the two techniques. Methods Between 2000 and 2014, 285 major pelvic and sacral resections were performed at one center. A total of 174 (61%) had complete data sets for analysis of blood loss, transfusion use, complications, and mortality at 90 days. Of those, 102 (59%) underwent hypotensive epidural anesthesia, whereas the remainder received standard anesthetic care. The anesthetic approach was determined by the anesthetists in charge of the case with hypotensive epidural anesthesia exclusively performed by one of two subspecialty trained anesthetists as their routine for major pelvic or sacral surgery. The groups were comparable in terms of potential confounding variables such as age, gender, tumor volume, and operation performed. Hypotensive epidural anesthesia was defined as a technique using an extensive epidural block up to T2-3 dermatome, peripherally administered low-concentration intravenous adrenaline infusion, and using unimpeded spontaneous respiration to achieve controlled hypotension, precise rate control of the heart, and enhanced velocity of venous return, all aggregated thus to minimize blood loss during pelvic surgery while preserving vital perfusion. The groups were assessed for perioperative blood loss calculated from pre-and postsurgery hemoglobin and transfusion use as well as postoperative complications, morbidity, and mortality at 90 days. Results There was less mean blood loss in the hypotensive epidural anesthesia group (1457 mL, SD 1721, 95% confidence interval [CI], 1114-1801 versus 2421 mL, SD 2297, 95% CI, 1877-2965; p = 0.003). Patients in the hypotensive epidural anesthesia group on average received fewer packed red cell transfusions (2.7 units, SD 2.9, 95% CI, 2.1-3.2 versus 3.9 units, SD 4.4, 95% CI, 2.9-5.0; Each author certifies that he, or a member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board members are on file with the publication and can be viewed on request. Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all in...

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Section: Discussionsupporting

confidence: 82%

Section: Introductionmentioning

confidence: 99%

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Hypotensive Epidural Anesthesia Reduces Blood Loss in Pelvic and Sacral Bone Tumor Resections

Freeman

Thorne

Gaston

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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show abstract

“…Venodilation has been a particular concern with epidural anesthesia, although recent studies suggest that this modality can be used safely. 5 Many anesthetic agents reduce systemic blood pressure and thereby reduce the aortic-coronary perfusion pressure gradient leading to reduced coronary blood flow. For surgical patients with significant AS, anesthetic management requires appropriate intravascular volume to optimize preload, heart rate control to allow adequate left ventricular filling along with time for coronary artery flow, and sufficient systemic blood pressure to maintain coronary artery blood flow.…”

Section: Pathophysiologymentioning

confidence: 99%

Core competency review: Aortic stenosis and noncardiac surgery

Wright

Hunt

2012

Journal of Hospital Medicine

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Aortic stenosis (AS) poses a risk of adverse cardiac events for patients undergoing surgical procedures. Perioperative mortality for patients with severe AS is as high as 14%. This review examines the accuracy of the history and physical examination in detecting AS and, subsequently, in assessing severity. The utility of echocardiography is addressed, and the relevant pathophysiology of AS is summarized. We also summarize what is known about perioperative risk for patients with AS. Journal of Hospital Medicine 2012;. © 2012 Society of Hospital Medicine

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“…Ho et al suggested the use of hypotensive epidural anaesthesia in patients with aortic stenosis undergoing total hip replacement and rendered satisfactory results provided that the stenosis is asymptomatic and non-critical. Nevertheless the choice of anaesthesia in such cases should be made on individual basis and in the presence of skilled anaesthetist [31].…”

Section: Epidural Blockmentioning

confidence: 99%

Anaesthetic Considerations for Patients with Severe Aortic Stenosis

Ghosh¹,

Bogár²,

Sabry³

2011

Aortic Valve Stenosis - Current View on Diagnostics and Treatment

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Hypotensive Epidural Anesthesia in Patients With Aortic Stenosis Undergoing Total Hip Replacement

Abstract: We report the absence of complications (with calculated upper limit 95% confidence interval of approximately 13.6%) when hypotensive epidural anesthesia was performed in 22 patients with noncritical asymptomatic aortic stenosis.

Cited by 17 publications

References 16 publications

Hypotensive Epidural Anesthesia Reduces Blood Loss in Pelvic and Sacral Bone Tumor Resections

Hypotensive Epidural Anesthesia Reduces Blood Loss in Pelvic and Sacral Bone Tumor Resections

Core competency review: Aortic stenosis and noncardiac surgery

Anaesthetic Considerations for Patients with Severe Aortic Stenosis

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