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Spinal Anesthesia in the Hospital Preoperative Area Before Taking the Patient to the Operating Room for Total Joint Arthroplasty

Abstract

Kapil Anand, Brian Mayeda, Brad Penenberg and Alex Macario

Background: As the number of total joint arthroplasty (TJA) cases continues to grow operating room (OR) suites can evaluate parallel processing strategies to reduce the length of time the patient is in the OR as a mechanism to increase throughput of cases. The goals of this study were to 1) assess the safety and success rate of performing spinal anesthesia in the hospital preoperative area and 2) measure the OR times for patients after the first case of the day undergoing total hip (THA) or knee arthroplasty (TKA) in an inpatient setting.

Methods: A retrospective review of electronic medical records (EMR) was performed on all patients after the first case of the day who underwent unilateral THA or TKA via spinal anesthesia by three orthopedic surgeons between January 2017 and December 2018. Spinal anesthesia was performed based on anesthesiologist preference either in the OR or in the preoperative holding area. Measured OR times included time from patient entry into the OR to: incision, surgery closure end, OR exit, and discharge from the Post Anesthesia Care Unit (PACU). Spinal anesthesia failure (inability to perform surgery without conversion to general anesthesia), high spinals requiring airway management, hypotension or bradycardia needing treatment in the holding area, and cardiac arrest were the primary clinical adverse events abstracted from the EMR.

Results: Twenty-five % (n=398) of a total of 1594 TJAs (720 THAs and 874 TKAs, 924 females and 572 males) received spinal anesthesia by 8 anesthesiologists in the preoperative holding area, with the remaining 1,196 patients receiving the spinal anesthetic in the OR. These 398 TJA patients had a mean and standard deviation (SD) of 70.7 (10.3) years of age, body mass index of 30.4 (6.7), American Society of Anesthesiologists (ASA) Physical Status of 2.3 (0.5) with 269 ASA 2 patients and 129 ASA 3 patients, with 36% males, and 42% undergoing THA. 100% of patients successfully had the spinal anesthetic with isobaric bupivacaine 0.5% (no additives) placed in the preoperative area, with no high spinals, and the time in minutes from entering the OR to: incision equaled mean (SD) of 42 (16), to surgery closure end 140 (21), OR exit 155 (20), and PACU discharge 297 (90). Complications included emesis (n=2), and persistent hypotension (n=4).

Conclusions: All 398 TJA patients had a spinal anesthetic successfully placed in the preoperative area with a minimal number of complications which provides evidence that anesthesiologists can choose patients in which spinal anesthesia is feasible and can be performed safely in the preoperative holding area.