Hypotensive epidural anesthesia provides arterial hypotension to maintain a mean arterial pressure of 50 mmHg and it can be used to reduce blood loss during total hip replacement. The technique combines an extensive epidural blockade with an intravenous infusion of low-dose epinephrine. This results in arterial hypotension, but with preservation of central venous pressure, heart rate, stroke volume, cardiac output, and an augmentation of blood flow to the lower extremity. The technique does not appear to adversely affect cardiac, renal, or cerebral function and is used safely in patients with hypertension, ischemic heart disease, and in the elderly. Intraoperative blood losses during primary total hip replacement are between 100 and 300 mL. Perioperative transfusions have declined with the introduction of the technique. Radiological evidence of improved fixation of cemented acetabular components has been observed. Rates of deep-vein thrombosis are low: 2-3% proximal deep-vein thrombosis with an overall rate of 10%. In-hospital mortality is 0.1%; lower than previously published rates. In conclusion, hypotensive epidural anesthesia is safe and provides a number of advantages over conventional anesthetic techniques for total hip replacement.