Spinal Anesthesia Using Chloroprocaine is Safe, Effective, and Facilitates Earlier Discharge in Selected Fast-track Total Hip Arthroplasty

Abstract

Background: Spinal anesthetic choice plays an underappreciated role in total hip arthroplasty (THA). Chloroprocaine, a short-acting local anesthetic, has been limited to short-duration ambulatory procedures and has not been studied in THA. We compare perioperative outcomes of patients undergoing fasttrack THA using chloroprocaine spinal anesthesia with those who have surgery with a longer-acting agent (bupivacaine). Methods: A total of 143 THAs performed under spinal anesthesia by 3 arthroplasty surgeons between November 2018 and July 2019 were retrospectively reviewed. Patients receiving chloroprocaine were matched 1:1 by demographics to patients receiving bupivacaine. Ultimately, 74 patients were included (37 chloroprocaine and 37 bupivacaine). The primary outcome was hospital length of stay (LOS). Other perioperative outcomes were also evaluated. Results: A total of 37 patients (50%) received chloroprocaine (60 mg), whereas 37 (50%) received bupivacaine (median 10 mg, range 8-15 mg). Among the matched groups, chloroprocaine use was associated with shorter hospital LOS (0.9 vs 1.2 days; P ¼ .03), shorter operative time (68.2 vs 83.6 minutes, P ¼ .03), lower estimated blood loss (184.7 vs 218.9 mL, P ¼ .02), shorter postanesthesia care unit LOS (139.4 vs 194.9 minutes; P ¼ .04), and less intraoperative hypotension (59.5% vs 83.8%, P ¼ .02). Patients receiving chloroprocaine were also more commonly discharged home (100% vs 89.2%; P ¼ .04). Conclusions: Chloroprocaine is a safe and reliable option for patients to mobilize rapidly and leave the hospital sooner after THA. Compared with bupivacaine, it is associated with shorter hospital LOS and higher likelihood for discharge to home.

Lower Dosing of Bupivacaine Spinal Anesthesia Is Not Associated With Improved Perioperative Outcomes After Total Joint Arthroplasty

“…An alternative to lower doses of bupivacaine is to choose a different agent altogether. Recent research has shown promising results for shorter acting agents such as chloroprocaine, especially in select patients that can have their surgeries performed quickly [ 24 ] .…”

Regional versus general anesthesia for ambulatory total hip and knee arthroplasty

“…It has been widely used in the ambulatory setting for knee arthroscopy and foot procedures and less commonly in TJA. In a retrospective study of fast-track inpatient THA, patients who received 2-chloroprocaine (60 mg) SA had shorter LOS, shorter operative time, shorter PACU stay, less hypotension, less intraoperative blood loss, and were more likely to be discharged home compared to those who received bupivacaine (8–15 mg) [22]. In a meta-analysis comparing 2-chloroprocaine to “low-dose” bupivacaine SA (defined as <10 mg) in ambulatory procedures, use of 2-chloroprocaine resulted in faster return of motor and sensory function, shorter time to ambulation, and faster time to ambulation with no difference in onset time [23].…”

Recommendations for total hip arthroplasty pain management: what’s old, what’s new and what continues to be missing?

“…Indeed, some of the current recommendations are not applicable to ambulatory hip replacement. Pain management for ambulatory hip replacement may feature one or more major practice modifications, such as use of short‐acting spinal anaesthetics, avoidance of intrathecal long‐acting opioids and avoidance of nerve blocks that compromise motor strength and impede ambulation [8]. Future research is obviously needed to determine whether or not a trade‐off between long‐acting intrathecal opioids and motor‐sparing blocks will improve patient outcomes.…”