Stavros G. Memtsoudis, Crispiana Cozowicz, Eugene R. Viscusi.
Response/Recommendation: The use of neuraxial anesthesia is associated with a reduced risk of venous thromboembolism (VTE) after lower extremity joint arthroplasty and should be considered as part of a multimodal prophylaxis regimen when feasible.
Strength of Recommendation: Moderate.
Rationale: Many orthopedic procedures performed on the extremities are amenable to regional (neuraxial and/or peripheral nerve blocks) instead of or in addition to general anesthesia. This approach has been linked to better pain control, sympathectomy-mediated vasodilatation, and reduction in the overall stress response1. Despite the many reported benefits of regional anesthesia in mitigating the risk of perioperative complications, data on the impact of regional anesthesia on the risk of thromboembolic events are available almost exclusively for total joint arthroplasty. Here, recent consensus group work by the International Consensus Group on Anesthesia Related Outcomes after Surgery (ICAROS), which was based on an extensive review and analysis of the literature, suggested that the use of neuraxial versus general anesthesia was associated with a 48% and 37% reduction in the risk of deep venous thrombosis and pulmonary embolism for total hip arthroplasty (THA), and a 33% and 21% reduction in the risk of the same endpoints for total knee arthroplasty (TKA), respectively2. This benefit was also noted when the analysis was restricted to studies wherein chemoprophylaxis was routinely used. Conclusions remained unaffected by the analysis of: 1) studies published after 1995 to reflect more contemporary practice, and 2) only randomized controlled trials as supposed to the inclusion of observational data. Additionally, when combining regional techniques with general anesthesia, additional benefit was observed, thereby suggesting an intrinsic benefit of neuraxial anesthesia that was separate from the avoidance of a general anesthetic approach.
There is a paucity of literature on the impact of regional anesthesia on thromboembolic risk in other types of orthopedic surgery. However, the choice of anesthetic and analgesic technique should also take into consideration additional adverse outcomes (i.e., risk of infection, pulmonary and cardiac compromise, etc.), many of which are substantially reduced with the use of regional anesthetic approaches. Further, the impact of anesthetic and analgesic techniques on VTE should be continually reassessed in light of recent advances such as those related to Early Recovery After Surgery (ERAS) pathways.
1. Kehlet H. Enhanced postoperative recovery: good from afar, but far from good? Anaesthesia. 2020;75 Suppl 1:e54-e61. doi:10.1111/anae.14860
2. Memtsoudis SG, Cozowicz C, Bekeris J, et al. Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis. Br J Anaesth. 2019;123(3):269-287. doi:10.1016/j.bja.2019.05.042