Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation

Abstract

Background Early ambulation after total hip arthroplasty predicts early discharge. Spinal anesthesia is preferred by many practices but can delay ambulation, especially with bupivacaine. Mepivacaine, an intermediate-acting local anesthetic, could enable earlier ambulation than bupivacaine. This study was designed to test the hypothesis that patients who received mepivacaine would ambulate earlier than those who received hyperbaric or isobaric bupivacaine for primary total hip arthroplasty. Methods This randomized controlled trial included American Society of Anesthesiologists Physical Status I to III patients undergoing primary total hip arthroplasty. The patients were randomized 1:1:1 to 52.5 mg of mepivacaine, 11.25 mg of hyperbaric bupivacaine, or 12.5 mg of isobaric bupivacaine for spinal anesthesia. The primary outcome was ambulation between 3 and 3.5 h. Secondary outcomes included return of motor and sensory function, postoperative pain, opioid consumption, transient neurologic symptoms, urinary retention, intraoperative hypotension, intraoperative muscle tension, same-day discharge, length of stay, and 30-day readmissions. Results Of 154 patients, 50 received mepivacaine, 53 received hyperbaric bupivacaine, and 51 received isobaric bupivacaine. Patient characteristics were similar among groups. For ambulation at 3 to 3.5 h, 35 of 50 (70.0%) of patients met this endpoint in the mepivacaine group, followed by 20 of 53 (37.7%) in the hyperbaric bupivacaine group, and 9 of 51 (17.6%) in the isobaric bupivacaine group (P < 0.001). Return of motor function occurred earlier with mepivacaine. Pain and opioid consumption were higher for mepivacaine patients in the early postoperative period only. For ambulatory status, 23 of 50 (46.0%) of mepivacaine, 13 of 53 (24.5%) of hyperbaric bupivacaine, and 11 of 51 (21.5%) of isobaric bupivacaine patients had same-day discharge (P = 0.014). Length of stay was shortest in mepivacaine patients. There were no differences in transient neurologic symptoms, urinary retention, hypotension, muscle tension, or dizziness. Conclusions Mepivacaine patients ambulated earlier and were more likely to be discharged the same day than both hyperbaric bupivacaine and isobaric bupivacaine patients. Mepivacaine could be beneficial for outpatient total hip arthroplasty candidates if spinal is the preferred anesthesia type. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Converting hip and knee arthroplasty cases to same-day surgery due to COVID-19

“…Mepivacaine has been shown to have a more predictable return of motor function after anaesthesia with a shorter half-life and also lower rates of urinary retention. 39 This was confirmed in the current study which decreased the incidence of urinary retention (5% in 2019 vs 0% in 2020), as well as slow recovery of neurological status (8% in 2019 vs 0% in 2020).…”

Postoperative outcomes of mepivacaine vs. bupivacaine in patients undergoing total joint arthroplasty with spinal anesthesia

“…The results of our study are in alignment with prior studies, demonstrating that mepivacaine use is associated with earlier ambulation, increased same-day discharge, and decreased length of stay [ 2 , 11 ]. Schwenk et al .…”

“…Prior studies have cited an expected 284% increase in total hip arthroplasty (THA) and a 401% increase in total knee arthroplasty (TKA) by the year 2030 [ 1 ]. In patients undergoing TJA, the use of different anesthetic techniques has also been shown to influence a variety of surgical outcomes, such as length of stay, time to ambulation, distance of ambulation, home discharge rate, and readmission or emergency department (ED) return rate [ 2 , 3 ].…”

“…This allows for a quicker onset for the hyperbaric bupivacaine and shorter duration of motor and sensory block compared to the slower onset and longer duration of action of the isobaric formulation [ 13 ]. One study found those treated with mepivacaine had earlier ambulation, earlier return to motor function, and were more likely to have the same-day discharge compared to those treated with hyperbaric or isobaric bupivacaine [ 2 ]. Another study used a double-blind, randomized clinical trial to investigate the effects of mepivacaine and bupivacaine on a patient’s return to motor function following total hip and knee arthroplasty and found a mean time of 26 minutes sooner with mepivacaine [ 3 ].…”

Analysis of Risk Factors for High-Risk Patients Undergoing Total Joint Arthroplasty

“…Multiple studies have identified preventative measures leading to lower length of hospital stays, decreased emergency department (ED) or readmission rates, and complications such as more aggressive rapid recovery and rehabilitation protocols and multimodal pain management [ [3] , [4] , [5] ]. In addition, increased preoperative education and care coordination has been associated with improved postoperative outcomes including reduced LOS and cost [ 6 , 7 ].…”