title: Neuraxial anesthesia decreases postoperative systemic infection risk compared with general anesthesia in knee arthroplasty.
abstract: BACKGROUND
  Surgical stress has been shown to result in immune disturbance. Neuraxial anesthesia (NA) has long been hypothesized to blunt undesired surgical insults and thus limit immune compromise and improve surgical outcomes. We hypothesized that NA would decrease postoperative infectious complications compared with general anesthesia (GA) among knee arthroplasty patients.
  
  
  METHODS
  We studied the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2010. There were 16,555 patients included in our final cohort, with 9167 patients receiving GA and 7388 patients receiving spinal or epidural anesthesia.. Outcomes of interest included infection-related 30-day postoperative complications, including surgical site-related infections, pneumonia, urinary tract infection, sepsis, septic shock, and a composite end point of any systemic infection. Multivariable logistic regression was performed to test for effect of anesthesia type while adjusting for the influence of preexisting comorbidities.
  
  
  RESULTS
  The overall mortality was 0.24% and 0.15% among NA and GA subjects, respectively (P = 0.214). NA subjects had fewer unadjusted incidences of pneumonia (P = 0.035) and composite systemic infection (P = 0.006). After risk adjustment for preexisting comorbidities, NA was associated with lower odds of pneumonia (odds ratio = 0.51 [95% confidence interval, 0.29-0.90]) and lower odds of composite systemic infection (odds ratio = 0.77 [95% confidence interval, 0.64-0.92]).
  
  
  CONCLUSIONS
  Our study suggested that NA was associated with lower adjusted odds of both pneumonia and a composite outcome of any systemic infectious complication within 30 days of surgery compared with GA.
authors.affiliation: From the Department of Anesthesiology and Critical Care, Perelman School of Medicine and Center for Health Outcomes and Policy Research, University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania.
authors.forename: Jiabin
authors.initials: J
authors.lastname: Liu
authors.forename: Chenjuan
authors.initials: C
authors.lastname: Ma
authors.forename: Nabil
authors.initials: N
authors.lastname: Elkassabany
authors.forename: Lee A
authors.initials: LA
authors.lastname: Fleisher
authors.forename: Mark D
authors.initials: MD
authors.lastname: Neuman
mesh_terms: D000368:Aged; D000767:Anesthesia, Epidural / Q000379:methods* / Q000639:trends; D000768:Anesthesia, General / Q000379:methods* / Q000639:trends; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D015331:Cohort Studies; D016208:Databases, Factual / Q000639:trends; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000175:diagnosis* / Q000517:prevention & control*
references.citation: Cochrane Database Syst Rev. 2003;(3):CD003071
references.pmid: 12917945
references.citation: J Pediatr Endocrinol Metab. 1995 Jul-Sep;8(3):187-94
references.pmid: 8521193
references.citation: Anesthesiology. 2010 Aug;113(2):279-84
references.pmid: 20657202
references.citation: Anesthesiology. 2007 Mar;106(3):499-506
references.pmid: 17325508
references.citation: Cochrane Database Syst Rev. 2004 Oct 18;(4):CD000521
references.pmid: 15494999
references.citation: Reg Anesth Pain Med. 2004 Nov-Dec;29(6):525-33; discussion 515-9
references.pmid: 15635510
references.citation: Reg Anesth Pain Med. 2012 Nov-Dec;37(6):638-44
references.pmid: 23080348
references.citation: Anesth Analg. 2010 Jun 1;110(6):1636-43
references.pmid: 20435944
references.citation: Anesth Analg. 1990 Jan;70(1):29-35
references.pmid: 2297102
references.citation: JAMA. 2012 Sep 26;308(12):1227-36
references.pmid: 23011713
references.citation: Am J Epidemiol. 2003 Aug 1;158(3):280-7
references.pmid: 12882951
references.citation: Anesthesiology. 2004 Jul;101(1):153-61
references.pmid: 15220785
references.citation: Br J Anaesth. 1988 Apr;60(5):500-7
references.pmid: 3377925
references.citation: Am J Epidemiol. 1999 Aug 15;150(4):327-33
references.pmid: 10453808
references.citation: Science. 2000 Jun 9;288(5472):1765-9
references.pmid: 10846153
references.citation: BMJ. 2000 Dec 16;321(7275):1493
references.pmid: 11118174
references.citation: J Bone Joint Surg Am. 2007 Aug;89(8):1675-84
references.pmid: 17671004
references.citation: Cochrane Database Syst Rev. 2006 Jul 19;(3):CD005059
references.pmid: 16856074
references.citation: Acta Anaesthesiol Belg. 1999;50(4):205-9
references.pmid: 10603996