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

Background and Objectives: For decades, hypotensive anesthesia has been use d in an attempt to reduce intraoperative blood loss. Hypotensive epidural a nesthesia (HEA) is a relatively new technique in hypotensive anesthesia. Us e of a tourniquet has been shown to be associated with a higher risk of car diovascular and thromboembolic complications. The effect of HEA on blood lo ss and need for transfusion in total knee replacement (TKR) is not known. Methods: Thirty consecutive patients scheduled for TKR were randomized to H EA. without tourniquet or spinal anesthesia with the use of a tourniquet (S PI). 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) ver sus 83 mm Hg (SPI) (P < .001). Intraoperative blood loss was 146 mt (HEA) v ersus 13 mt (SPI) (P < .001). Postoperative blood loss at any time was sign ificantly reduced in the HEA group, and total loss of blood was 1,056 mt (H EA) versus 1,826 mL (SPI) (P < .001). Half of the bleeding took place durin g 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 gr oup (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 witho ut a tourniquet. Compared with spinal anesthesia, the use of HEA for TKR si gnificantly reduces blood loss and the need for blood transfusion.