Combined spinal-epidural anesthesia is an efficient technique for conserving operating room time during total joint arthroplasty

Introduction. The advantages of combined spinal-epidural anesthesia (CSE) in obstetric practice are well documented (1), while its benefits for orthopedic procedures are just being explored (2). Recently, the use of regional anesthesia techniques that extend analgesia into the postoperative period has been shown to improve the outcome and shorten the rehabilitation after total knee arthroplasty (TKA) (3). We sought to determine the effect of CSE, which combines the advantages of short onset time with the capacity for post operative analgesia, but is technically more complex to perform, on operating room efficiency. Methods. A retrospective chart review was undertaken of all total hip arthroplasties (THA) and TKAs, occurring between February 1 and July 31, 1999, at a 1,200 bed tertiary care university hospital center. Data were acquired using a computerized system (CompuRecord Anesthesia Records, Inc., Pittsburgh) which has touch screen entry for sentinel events, including anesthesia start (AS), positioning time (PT), surgery start (SS), surgery finish (SF) and anesthesia finish (AF). Anesthetic techniques included CSE, general (GA), epidural (EA) and spinal anesthesia (SA) in the THA group and GA, CSE and EA in the TKA group. AS=>SS, AS=PT. SF=AF and the sums of these surgery/surgeon independent time points were calculated for the THA group, while times to positioning were not considered for the TKAs, which are performed in the supine postilion. Kruskall Wallis tests were used to detect an overall difference among the different techniques. Differences between any two techniques were detected using a Mann Whitney U test. Results. Complete data were available for 62 THAs and 60 TKAs. Data for three failed regional anesthetics that were converted to GA in the THA group, and one conversion to GA prior to SS in an uncooperative patient in the TKA group, were excluded. Mean times for each interval appear in the table: THA TKA TIME (sees) CSE n=30 E A n=15 GA n=17 CSE n=22 EA n=10 GA n=6 SA n=22 SS~AS (1) S9.S 73 59 59.5 67.5 37.5 63 PT~AS (2) 29 41 28 - - AF-SF (3) 19 19 18 17 20 19 22 1+3 77.S 90 78 2+3 46.5 65 47 78 84.5 60 81 For the THA group the SF=>AF times were not significantly different among the three anesthetic techniques as were all live time calculations between the CSE or GA groups. Times to accomplish EA were significantly greater (p<0.05) than both CSE and GA at AS=>SS, AS=>PT, and thus, also for the cumulative times. The SF^AF times were similar among the four anesthetic techniques in the TKA group. We found no significant differences among the AS=>SS times for any of the regional anesthetic techniques, but AS=SS time of GA was significantly shorter (pO.05) than each of the other groups. Discussion. Time to perform CSE was not longer than that of EA or SA, and thus its use did not negatively impact overall anesthesia times in any group. Onset advantages decreased time to positioning, make CSE a preferable technique to EA for THA. Although GA remains the most efficient technique, the intraoperative, and now postoperative, advantages of regional anesthetic techniques must be considered when developing anesthetic plans for patients undergoing total joint arthroplasty.