Hypotensive epidural anesthesia in total knee replacement without tourniquet: Reduced blood loss and transfusion

Background and Objectives: For decades, hypotensive anesthesia has been used in an attempt to reduce intraoperative blood loss. Hypotensive epidural anesthesia (HEA) is a relatively new technique in hypotensive anesthesia. Use of a tourniquet has been shown to be associated with a higher risk of cardiovascular and thromboembolic complications. The effect of HEA on blood loss and need for transfusion in total knee replacement (TKR) is not known. Methods: Thirty consecutive patients scheduled for TKR were randomized to HEA. without tourniquet or spinal anesthesia with the use of a tourniquet (SPI). HEA was performed as an epidurally induced sympathetic block and there was an infusion of low-dose epinephrine to stabilize the circulation. Results: Intraoperative mean arterial blood pressure was 48 mm Hg (HEA) versus 83 mm Hg (SPI) (P < .001). Intraoperative blood loss was 146 mt (HEA) versus 13 mt (SPI) (P < .001). Postoperative blood loss at any time was significantly reduced in the HEA group, and total loss of blood was 1,056 mt (HEA) versus 1,826 mL (SPI) (P < .001). Half of the bleeding took place during the first 3 postoperative hours and 80% during the first 24 hours. In the HEA group, 57% of the patients went through surgery and the hospital stay without receiving blood transfusion versus 19% in the SPI group (P < .05). There was a significantly reduced amount of blood transfusion in the HEA group (193 mt) versus 775 mt in the SPI group (P < .005). No cardiopulmonary, cerebral, or renal complications were registered. Conclusions: We conclude that HEA is a safe technique that allows TKR without a tourniquet. Compared with spinal anesthesia, the use of HEA for TKR significantly reduces blood loss and the need for blood transfusion.