Letters to the Editors / The Journal of Arthroplasty 31 (2016) 548–558

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The Journal of Arthroplasty

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Letters to the Editors

Epidural Anesthesia and Perioperative Hypotension
In a retrospective study, Patel and colleagues [1] claimed that pe-
ripheral nerve blocks (PNB) were safe and effective for same day bilat-
eral total knee arthroplasty (TKA) with a significant decrease in
perioperative hypotension compared to epidural anesthesia, and that
epidural patients required more blood transfusions and greater volumes
of fluids. Although the paper did not provide the reasons for hypoten-
sion and the measures how to prevent and treat it, we think it is inap-
propriate to meet the normal blood pressure (BP) with only more
fluids and blood transfusions and that as such doctors would have to
consider more options.
Perioperative hypotension is more likely to happen under epidural
anesthesia, especially general anesthesia combined with epidural anes-
thesia [2]. The primary reason for this hypotension may be arterial vaso-
dilation because of residual effects of anesthesia, but not pre-load
deficiency or myocardial depression. It is certainly reasonable to sup-
port hypotension with a vasopressor (such as phenylephrine). Excess
fluid or inotropic therapy is inappropriate, or even harmful for those pa-
tients soon after bilateral TKA. Because excess fluid would dilute the
blood and reduce the hemoglobin concentration, thereby increase the
possibility of iatrogenic blood transfusion. So the epidural group in
their study required more blood transfusions and greater volumes of
hespan and crystalloid which would cause excessive pre-load once the
residual effects of anesthesia gradually disappeared. While inotropic
therapy would cause the relatively greater loss of parasympathetic ac-
tivity which would increase perioperative morbidity [3]. On the other
hand, we do not think it is appropriate for all patients in the epidural
group to receive laryngeal mask anesthesia since epidural analgesia
can provide adequate analgesia for bilateral TKA. IV sedation applying
a small dose of propofol or dexmedetomidine might be a better choice.
Yongxin Liang, MD
Shiduan Wang, MD ⁎
Department of Anesthesiology
The Affiliated Hospital of Qingdao University
Qingdao, China
⁎ 499 Farmington Avenue, Suite 300, Farmington, CT 06032
Reprint requests: Shiduan Wang, MD, Department of Anesthesiology
The Affiliated Hospital of Qingdao University, 16 Jiangsu Road
Qingdao, China, 276000
2. Liang Y, Chu H, Zhen H, et al. A prospective randomized study of intraoperative thoracic
epidural analgesia in off-pump coronary artery bypass surgery. J Anesth 2012;26:393.
3. Botto F, Alonso-Coello P, Chan MT, et al. Myocardial injury after noncardiac surgery: a
large, international, prospective cohort study establishing diagnostic criteria, charac-
teristics, predictors, and 30-day outcomes. Anesthesiology 2014;120:564.
Epidural Anesthesia and Perioperative Hypotension
In Reply:
The authors appreciate the important observation that excess fluid
or inotropic therapy following same day bilateral total knee arthroplasty
performed under epidural anesthesia may be harmful to this group of
patients. For many years, these patients were kept in the PACU for
close monitoring with particular attention to avoiding fluid overuse
and minimizing inotropic support.
In our study, the primary endpoint was postoperative hypotension
and secondary outcomes were fluid volume, transfusion, or other mea-
sures such as pruritis. We agree that perioperative hypotension is more
likely to occur under epidural anesthesia than with the use of peripheral
nerve block and this is the main conclusion of our study.
The authors acknowledge that this retrospective cohort study lacks
the methodologic rigor of an RCT; the study was performed as a pilot
in anticipation of such a prospective investigation. Based on our ob-
servations, we were not ethically able to initiate that study given
the clear differences in post-operative course with peripheral
nerve block patients experiencing a dramatically more stable
course in the PACU and immediate post-operative phase of
their care.
Courtland G. Lewis, MD
Connecticut Joint Replacement Institute, Farmington, Connecticut
Reprint requests: Courtland G. Lewis, MD, Orthopaedics
http://dx.doi.org/10.1016/j.arth.2015.06.042

http://dx.doi.org/10.1016/j.arth.2015.06.023

References
1. Patel N, Solovyova O, Matthews G, et al. Safety and efficacy of continuous femoral
nerve catheter with single shot sciatic nerve block vs epidural catheter anesthesia
for same-Day bilateral total knee arthroplasty. J Arthroplasty 2015;30:330.

No author associated with this paper has disclosed any potential or pertinent conflicts No author associated with this paper has disclosed any potential or pertinent con-
which may be perceived to have impending conflict with this work. For full disclosure flicts which may be perceived to have impending conflict with this work. For full disclo-
statements refer to http://dx.doi.org/10.1016/j.arth.2015.06.023. sure statements refer to http://dx.doi.org/10.1016/j.arth.2015.06.042.

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