Anesthesia for Orthopedic Surgery

8/13/2019 Anesthesia for Orthopedic Surgery

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Jeremy Rainey, OMS-IV


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Preoperative Considerations

Most patients suffer from

Osteoarthritis

RA (which carries important considerations for us)

Avascular Necrosis

Total Hip Arthroplasty


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Rheumatoid Arthritis

Immune-mediated joint destruction with chronic inflammation ofsynovial membranes

NOT regular wear and tear

Establishing venous access can be difficult in this population

Table 401. Systemic Manifestations of Rheumatoid Arthritis.

Organ System Abnormalities

Cardiovascular Pericardial thickening and effusion, myocarditis, coronary arteritis, conduction defects,

vasculitis, cardiac valve fibrosis (aortic regurgitation)

Pulmonary Pleural effusion, pulmonary nodules, interstitial pulmonary fibrosis

Hematopoietic Anemia, eosinophilia, platelet dysfunction (from aspirin therapy), thrombocytopenia

Endocrine Adrenal insufficiency (from glucocorticoid therapy), impaired immune system

Dermatological Thin and atrophic skin from the disease and immunosuppressive drugs


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Rheumatoid Arthritis contd

Exercise tolerance can sometimes not be assessed due to limited mobility

Use Dipyridamole thallium scanning or dobutamine ECHO for evaluation

Odontoid process protrusion

May be seen in severe cases

Risk of vertebral circulation compromise during induction

May compress spinal cord or brain stem


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If atlantoaxial instability exceeds 5mm, awake fiberoptic intubationshould be used.

Postextubation airway obstruction is also of concern due tocricoarytenoid arthritis.

RA/OA patients commonly treated with NSAIDs

Can cause GI bleeding, renal toxicity, platelet dysfunction

COX-2 inhibition gives pain relief and antiinflammatory properties

COX-1 inhibition generally responsible for SEs


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Involves several steps: Positioning- usually lateral decubitus

Dislocation of femoral head

Reaming of acetabulum

Insertion of prosthetic acetabular cup (w/wo cement)

Reaming of femur and insertion of femoral head/stem into femoral shaft

Three potentially dangerous complications

Bone cement implantation syndrome

Hemorrhage

VTE

Intraoperative mgmt THR


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BCIS characterized by hypoxia, hypotension or both and/or unexpected loss of

consciousness occurring around the time of cementation, prosthesis insertion,

reduction of the joint or, occasionally, limb tourniquet deflation in a patient

undergoing cemented bone surgery

Severity

Grade 1: moderate hypoxia (Spo220%].

Grade 2: severe hypoxia (Spo240%) or

unexpected loss of consciousness.

Grade 3: cardiovascular collapse requiring CPR.

Intraop mgmt THR


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Invasive monitoring generally recommended

Prior to cementing, increasing FiO2 may decreased risk of VTE

Neuraxial anesthesia helps decrease risks.

Neuraxial anesthesia alone or when combined with general anesthesia may reduce

thromboembolic complications by several mechanisms. These include

sympathectomy-induced increases in lower-extremity venous blood flow, systemic

antiinflammatory effects of local anesthetics, decreased platelet reactivity,

attenuated postoperative increases in factor VIII and von Willebrand factor,

attenuated postoperative decreases in antithrombin III, and alterations in stress

hormone release. Intravenous lidocaine has been shown to prevent thrombosis,

enhance fibrinolysis, and decrease platelet aggregation

Epidurals, spinals may also be used as well as typical LCDs andanticoagulants.

Intraop mgmt THR


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Bilateral hip arthroplasties can be safely performed during oneanesthetic, assuming the absence of significant pulmonary embolizationafter insertion of the first femoral component.

Look for a rise in pulmonary arterial pressure with unchanged pulmonary arterial

occlusion pressure with falling heart rate

An increase in pulmonary vascular resistance reliably signals embolization

Pressures above (200 dyn x s x cm5) require contralateral surgery to be postponed.

NOTE: Bilateral UNCEMENTED HAs dont require PA pressure monitoring.

Consider epidural for post-op pain.

Bilateral Hip Arthroplasties


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In particular may be associated with moderate to severe surgical bloodloss.

Controlled HYPOtension combined with regional techniques may helpdecrease blood loss.

Thought behind this is redistribution of blood flow away from bone surface whichimproves prosthetic cementing and shortens duration of surgery.

Autologous blood donation should be considered

High-dose aprotinin, a proteinase inhibitor of fibrinolytic activity and the

intrinsic coagulation pathway by decreasing activation of plasminogen,may reduce intraoperative blood loss in patients undergoing revisionsurgery.

Does not seem to increase risk of PE/DVT

Can also give EPO (increases RBC production)

Revision Arthroplasty


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Development of MIT for cementless hip replacement.

In some setting may allow for robotic assisted surgery.

Computer-assisted surgery improves surgical outcomes

Can construct 3D images of bone and soft tissue based of pt radiographs, CTs, etc.

Allows for improved preop planning and simulation

CAS allows optimal placement with great accuracy of implants

MIT may reduce hospital length of stay to 24h or less.

Minimally Invasive Arthroplasty


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Anesthetic plans Epidural anesthesia

Propofol infusion

LMA

May eliminate the need for parenteral opioids intraop!

Premedication with oxycodone 10 mg (orally), valdecoxib 20 mg (orally),and acetaminophen 500 mg (orally).

Versed 1-2 mg

Antiemetic prophylaxis

Lido 2% epidural provides surgical anesthesia (addition of catheter allowsfor addition administration)

Postop pain handled with hydrocodone and acetaminophen and NSAIDs.

Minimally Invasive Arthroplasty


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3% incidence of hip dislocation following hip arthroplasty

20% following total hip revision

Reduced with CAS

Less force required to dislocated implant

OR staff needs to be aware of extremes of positioning

Gen Anesthesia via facemask or LMA is usually sufficient

Succinylcholine may provide facilitation Propofol may be enough

Confirm reduction with X-ray

Closed Reduction Hip Dislocation


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Typically outpatient

Athletes to the elderly

Arthroscope used to evaluate conditions such as torn floating cartilage,surface cartilage, ACL reconstruction, trimming of damaged cartilage.

Joint not fully opened (yay MIT)

Usually 2 incisions

Knee Arthroscopy


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Use of pneumatic tourniquet helps to reduce blood loss

Pt usually supine

General anesthesia performed in a majority of cases with LMA.

Neuraxial anesthesia also used

Femoral nerve, lateral femoral cutaneous nerve, and sciatic blockscommonly used for post operative anesthesia of knee.

Epidural and spinal anesthesia produce equivalent pt satisfaction

Though roughly 30% of patients will complain of back pain following these

procedures

Intraop mgmt Knee Arthroscopy


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Recovery depends on..

Patient GETTING UP AND MOVING

Adequate pain relief and PONV control also appreciated

Systemic ketorolac + intraarticular steroid injectios an option Of course neuraxial blocks

Postop Knee Arthroplasty


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Patients are of similar population to those undergoing total hipreplacement

RA, OA, etc.

Total Knee Replacement


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Shorter than hip replacement

Supine position

Blood loss reduced by tourniquet use

If cooperative, patients can generally tolerate regional blockade withintravenous sedation

BCIS is less likely to occur, but risk following insertion of femoralprosthetic is possible.

This may exaggerate any tendency for hypotension following tourniquet letdown.

MONITOR PAOP.

Consider placement of epidural catheter preoperatively. Knee proceduresare typically much more painful than hip so addition of this may help toalleviate some postop pain and allow for more successful physical therapyearlier.

Especially useful for bilateral knee replacements

Intraop mgmt Total Knee Replacement


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Epidural ropivacaine 0.2% at 5-10 mL/h Good analgesia

Minimal motor blockade for 48-72 hours

Femoral sheath catheter may have fewer side effects than epidural

Intraop mgmg TKR


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Limited approach has reduced muscle damage, more suitable for earlyambulation, and may allow for discharge as early as 24hrs postop.

Anesthetic approach same for total knee or hip.

Partial Knee Replacement


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Shoulder Subacromial impingement

Rotator cuff tears

Traumatic fractures

Nerve entrapment (carpal tunnel, cubital tunnel) Joint arthroplasties (RA)

Surgery on Upper Extremity


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Can be open or arthroscopic

Utilize beach chair position or lateral decubitus position

Interscalene brachial plexus blockade is excellent for these procedures

Provides good postop analgesia

Saves intense muscle relaxation commonly required if this blockade is notperformed

Indwelling interscalene catheter can provide up to 48hrs of postop analgesia

following major shoulder operations.

Ropivacaine 0.2% infused at 4-8 mL/h

Shoulder Surgery


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Ketorolac at the end of the procedure and w/in first 24hrs can reduce postopopioid requirements

SHHHHHI promise its yourDilaudid!


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Carpal tunnel release One of the most common operations in anesthetic practice

Intravenous Regional Anesthesia (Bier Block) is ideal

Tourniquet placed on proximal arm of extremity (double cuff)

IV catheter introduced into dorsum of patients hand

Arm exsanguinated

Lidocaine injected into IV. Diffusion of anesthetic from vessels to nerve providesanalagesia.

Pins and needles sign most common pt report within 5 minutes, though commonlymissed in current practice due to Versed administration.

Careful release of tourniquet must be taken to avoid systemic toxicity, hematomas,extremity engorgement, or subcutaneous hemorrhage.

Brachial plexus block may be preferred for operations lasting 1h

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Anesthesia for Orthopedic Surgery