Perioperative Management Considerations in Orthopedic

Surgery

Michael H. Wilhelm, CRNA, APRN

Who am I???CRNA at Hartford HospitalGraduated from HSR 2012Come from NYC and worked in a Medical ICU for

2 years at North Shore Manhasset Hospital in Long Island, NY

Education Norwich University B.S. Electrical Engineering New York University B.S. Nursing CCSU/HSR M.S. Biology

Where do I find these slides?

http://ct-cpr.com/?page_id=195

What if we have a question??

Email: wilhelmmi@gmail.comPhone: 347-739-6947 (Call or Text)

What if something you taught is was not correct on the test??Disclaimer

I am not personally responsible for the material that will be on your exam. I suggest that you still read the book and if the information in the book conflicts with what I have taught you I would suggest you use that information and can use my information once you graduate and pass your written Boards.

Problems During Orthopedic Procedures

Bone Cement ProblemsPneumatic TourniquetsFat Embolism SyndromeDeep Venous Thrombosis & Thromboembolism

Bone Cement ProblemsPolymethylmethacrylate

Mixing powder and liquid causes an exothermic reactionPolymerized methylmethacrylate powderMethylmethacrylate monomer liquid

Reaction causes the expansion of cement and forces fat, blood and air into the femoral venous channelsCan result in greater than 500mmHg pressure

Residual monomer (liquid) is a potent systemic vasodilator and pulmonary vasoconstrictor

Release of tissue thromboplastin may trigger thromboembolism and cause hemodynamic instability

Clinical ManifestationFever HypoxiaHypotensionTachycardiaDysrhythmiaMental status changeDyspneaEnd tidal CO2 decreaseRight ventricular failure and cardiac arrest

QuestionWhen do emboli most frequently occur?

AnswerDuring the insertion of a femoral prosthesis for

hip arthroplasty

Treatments Increased inspired oxygen concentration prior

to cementingMonitoring to maintain euvolemiaCreating a vent hold in the distal femur to

relieve intramedullary pressurePerforming high pressure lavage of the femoral

shaft to remove debrisUsing a femoral component that requires no

cement

Tourniquets• Pneumatic Tourniquets• Provide virtually bloodless field• Cuff should overlap only 3 to 6 inches• Area underneath must be padded and wrinkle-free• Overlap of cuff should be opposite of neurovascular bundle (e.g.

on the humerus, overlap is on the lateral aspect-opposite the brachial plexus)

• Inflation pressure usually 100mmHg greater than systolic blood pressure

• Anesthesia responsibility : • Adequate preoperative assessment.• Proper size, properly fit.• Accurate, effective pressure.• Systolic blood pressure and cuff pressure. • Inform surgeon tourniquet time.

TourniquetsMust exsanguinate extremity prior to inflation

(elevate or use Esmarch bandage)Elevation is preferred in infected extremitiesInflation pressures

• Should not exceed 300mmHg in upper extremities• Typically 250mmHg

• Should not exceed 500 mmHg in lower extremities• Typically 350mmHg

Why do we Like/Not LikeAdvantage

Eliminate intraoperative bleedingDisadvantages

Neurologic effect Muscle change Systemic effects of the tourniquet inflation Systemic effects of the tourniquet release

Neurologic EffectsTourniquet pain and hypertension If > 45-60

minsNeurapraxia if > 2 hoursNerve injury at the skin level the edge of the

tourniquet

Muscle ChangesCellular hypoxiaCellular acidosisEndothelial capillary leakLimb becomes colder

Systemic Effect of Tourniquet Inflation

Arterial Pressure Elevated

Systemic Effect of Tourniquet Release

Transient fall in core temperatureTransient metabolic acidosisRelease of acid metabolites into central

circulationTransient fall in arterial pressureTransient increase in EtCO2

Tourniquet Pain• Compression of intra-neural blood vessels

• Causes secondary nerve ischemia• Leads to stimulation of pain pathways

• Onset 45-60 minutes after inflation• Similar to thrombotic vessel occlusion• Activation of C fibers – burning and aching• Activation of A delta fibers – pins and needles

• Difficult to treat, once it begins: analgesics and anesthetics have little effect, may need to treat sympathetic activation (tachycardia and hypertension)-What is the only true treatment?

Effects of Tourniquets

Tourniquet Safety• Always place cuff where nerves are best

protected in the musculature• -Check proper function of machine• -Never inflate for longer than 2 hours: 10 to 15

minute reperfusion interval required prior to re-inflation

• -Minimally effective pressure to occlude blood flow

• -Put display where you can see it• Report 60 minutes, then 15 min increments after that

to the surgeon and be sure to chart that you did so• Always chart times on your record

Tourniquet problems Nerve Injury Post - Tourniquet Syndrome Compartment Pressure Syndrome Intra operative Bleeding Pressure Sores and Chemical Burns Digital Necrosis Toxic Reactions Thrombosis Tourniquet pain Other Complications

NERVE INJURYUpper extremity, radial nerve.Transient to irreversible loss of function. Irreversible Tourniquet paralysis syndrome.Loss of sensory and motor function.

Causes : Excessive, insufficient pressure.Mechanical stress ischemia or anoxia (N)Slow or cessation of sensory or motor conduction.

PREVENTIVE MEASURESTourniquets use only recommended time. Check accuracy of the pressure.Do not use faulty pressure gauge.Effective pressure to achieve limb occlusion pressure. Use a cuff that properly fits the extremity.Apply the cuff to the limb with care and attention. Apply the cuff at the proper location on the limb. Don’t apply over the peroneal nerve or ulnar nerve. Avoid tourniquet to slip or twist - limb manipulation. Do not pinch or kink the connecting tubing.

POST TOURNIQUET SYNDROMEPostischemic reactive hyperemia. To restore normal acid base balance in tissue. Prolonged bleeding from surgical wound. Edema, stiffness, pallor, weakness, paralysis. CAUSES :Prolonged ischemia neuromuscular injury.Under pressurized cuff.Calcified vessels – elderly, R.A. with steroids.

Preventive measures

Good preoperative history & assessment.History of steroids, aspirin & oral contraceptives. History of hypertension. Coagulation profile.History of thromboembolic occurrences. Evidence of arterial calcification. Strict with the recommended tourniquet time limit.Use arterial occlusion pressure than systolic BP.

Compartment syndrome Relative complication of tourniquet. External and internal pressures - pain. Tense skin, swelling, weakness, parasthesia. Absent pulse – irriversible paralysis. Causes & prevention : Trauma or surgery, time, pH. capillary permeability, Prolongation of clotting. Preoperative evaluation Time < 90 minutes.

Intraoperative bleeding

Causes : An under pressurized cuff. Insufficient exsanguinations. Avoid too slow inflation and deflation. Improper selection of cuff. Excessive padding. A cuff that is applied too loosely. Preventive measures : Select the proper style and size of tourniquet cuff. Good exsanguinations, some times re-exsanguinations. Consider to Re-inflation higher pressure.

Toxic reactions IVRA – deflation, under inflation, faulty, sudden

release LA circulation. Symptoms – immediate – CNS & heart. Prevention : Test the tourniquet Allergic history, CVS, CNS, Vascular problems.Dual bladder cuff, limb occlusion pressure. Intermittent deflation and reinflation.Observe the patient’s phsyiological status.

Pressure sores and chemical burns Less with pneumatic, pressure / time or both. Sensitive skin of children, discomfort to the patient. Chemicals, fluid accumulation under the cuff.Causes & Prevention : Inadequate padding or faulty cuff. Loose, thin or flabby skin. Skin breakdown, friction, or soft tissue folding. Leak under the cuff, position of the cuff. Correct limb protection technique. Do not readjust by rotation damage the tissues.

Digital necrosis : Prolonged, constrictive, excessive/uncontrolled

pressure.Results ischemia/anoxia gangrene. Avoid, pressure drain, rubber/glove band. Thromboses : DVT, PE, lower extremity surgery.PE – tourniquet related cardiac arrest. Prevent dislodgement, subtherapeutic

heperinization. Avoid elastic bandage for exsangunation.

OTHER PROBLEMSTourniquet pain :

Dull aching, some times severe pain, HTN. After deflation – reperfusion – different pain. Pain tolerance after inflation of cuff – 30 min

unsedate.Thermal Damage to Tissues.Hyperthermia.Rhabdomyolysis.Metabolic Changes

QuestionWhy do we see a decrease in blood pressure

when we deflate the tourniquet?

AnswerWe first have resolved the tourniquet pain that

may have been present Usually after 1 hour of inflation Causes marked tachycardia, hypertension and

diaphoresisRecirculation of the area presents washout of

all the metabolic waste that were in the extremity, this will cause a remarkable but self-resolving decrease in blood pressure Finally something you can relate to immunology

Fat Embolism• High correlation with long bone, hip, and pelvic

fractures• Occurs, to some degree, in all hip fracture

patients• Patients typically have low oxygen saturation

and low-grade fever• Fat Embolism Syndrome

• Presents within 72 hours of injury• 3 hallmark signs: confusion, dyspnea, petechiae

(especially on upper extremities and chest)• Fat globules released into the blood through tears in

medullary vessels (Seen in Retina, Urine and Sputum)

• Theory that chylomicrons result from aggregation of circulating fatty acids

• Thrombocytopenia and prolonged clotting times may occur

Fat Embolism under General

• Diagnosing fat embolism syndrome under General Anesthesia• Decline in end tidal CO2• Decline in arterial oxygen saturation• Rise in pulmonary artery pressures• Ischemic-appearing ST segment changes• Right sided heart strain

Clinical Findings Cardiovascular

Persistent tachycardia, hypotension Respiratory

Dyspnea hypoxia hemoptysis Cerebral

Delirium stupor seizure coma Ophthalmic

Retinal hemorrhage Cutaneous

petechiae Other

Jaundice fever

TreatmentProphylactic

Early stabilization of the fractureSupportive

Respiratory careMaximize O2, ventilation

Invasive monitorVolume status

Inotrope High dose corticosteroid

Hip Fractures

Hip Surgery• -ORIF – Open Reduction with Internal fixation

• Done for fractures (usually frail/elderly)• Requires use of special fracture table (legs split with traction

applied)• Frequent concomitant diseases (dementia, Parkinson’s, CAD,

diabetes, etc.)• Frequently dehydrated

• Occult blood loss can be significant• Intracapsular

• Subcapital, transcervical – less blood loss• Extracapsular

• Femoral neck, intertrochanteric, subtrochanteric – expect higher blood loss

• -Bipolar hip replacement (not a total hip arthroplasty): • -done when fracture is not amenable to permanent

fixation• - femoral head and partial femoral neck are resected

and replaced with a prosthesis• -acetabular component is not fixed to the acetabulum• -procedure usually takes less than an hour

Bipolar Hip Prosthesis•Cup is not attached to acetabulum•Utilized when patient will be non-

ambulatory or will limit weight-bearing activities on hip for the rest of his life

Anesthetic Choice in Hip Fracture

• General or Regional?• Extensively evaluated• Regional has lower mortality in the first 2

months post surgery• No significant difference in mortality after 2

months• General is associated with more thrombo-

embolic events than regional• Morbidity post-general is higher immediately

post operatively

Total Hip Arthroplasty• -Usually done in lateral decubitis position

• Higher degree of visibility and range of motion

• -Most common indication is Osteoarthritis (OA) AKA Degenerative Joint Disease (DJD)

• -Surgical Concerns (large incision, muscle trauma):• Acetabulum and femoral head/neck are very

vascular• Resection of femoral head and neck• Reaming of femoral shaft to accept stem• Reaming of acetabulum to accept cup

• Three life threatening complications• Bone cement implantation syndrome (cement

rarely utilized in primary arthroplasty)• Peri-operative hemorrhage• Thrombo-embolism

Total Hip Replacement*Minimally invasive/muscle sparing techniques are in widespread use

Closed Hip Reduction• May be necessary if prosthesis dislocates• Often done with heavy MAC or IV general

with short-acting muscle relaxant, unless contraindicated

• Extremes of flexion and internal rotation can dislocate a new prosthesis- abduction pillow is placed immediately post-operatively to avoid dislocation

• Repeated dislocation of a hip prosthesis may require revision of the prosthesis-this is usually a failure of either surgical technique or the implant itself

Total Knee Arthroplasty• Usually done for osteoarthritis or late-stage

rheumatoid arthritis• Supine position• Regional vs. general anesthesia• Cement implantation syndrome (when is this a

concern?)• Tourniquet concerns (ensure it is working)• Autologous blood donation

• Bleeding is usually an issue post-op (once tourniquet is down)

Revision Joint Replacements• Previous joint replacements may need to

be revised• Lifespan of current implants is postulated

to be 10 to 15 years (may be shorter or longer, depending on recipient use)

• Revision procedures tend to be lengthy and bloody

• Intra-operative cell salvage is usually recommended

• Infected joints need to be removed, with placement of antibiotic spacers until infection resolves-don’t use cell savage in suspected infection cases

Upper Extremity Procedures• -Usually amenable to brachial plexus block

(interscalene, supraclavicular, axillary)• Shoulder arthroplasty or arthroscopy

• Requires beach chair/sitting position• Venous air embolism precautions• Airway concerns• Cardiovascular considerations?

• Elbow arthroplasty or arthroscopy• Prone position• Turn head away from field• Turn table 90 degrees

Shoulder ArthroplastyPainful!!

PositioningSupine LateralProneBeach chairFracture table

Why is positioning important?

Enable IV and catheter to remain patentEnable monitors to function properlyFacilitates the surgeon’s approachPatient safety

Supine Patient on backArms on arm boards

Arm < 90 degrees Arm is supinated ( palm up) Place padding under elbow if able

Arm tucked Check fingers Check IV lines and SaO2 probe

Lateral Decubitus PositionUsed in thoracic, renal, and orthopedic

procedures• Presents unique challenges to the

anesthetist• Importance of body alignment

(cervical/thoracic/lumbar)• Use of bean bag, axillary roll, pillows,

sandbag– Cardiovascular Considerations– Respiratory Considerations

• FRC decreased• Ventilation/Perfusion mismatch• Atelectasis• Use of PEEP (may worsen mismatch)

Lateral Decubitus

LateralBody alignment

Keep neck in neutral position Always place axillary roll Place padding between knees Place padding below lateral aspect of dependent

leg

LateralPosition arms to parallel to one another

Place padding between arms or place non-dependent arm on padded surface

ProneFace downHead placement

Head straight forwardET tube placement and patencyCheck bilateral eyes/ears for pressure points

Head turnedCheck dependent eye/ear, ETT placement Be aware of potential vascular occlusion

ProneArm placement

Tucked – similar to supine Abducted

Check neck rotation and arm extension to avoid brachial plexus injury

Elbow are paddedChest rolls Iliac support

Padding in placed under iliac crests

Injury occuring from prolonged positioning

Eye compression in prone positionSkin breakdown due to prolonged positioning

Research ArticlesJournal of Shoulder and Elbow Surgery Oct 2013“Cerebral oxygenation in the beach chair position: a prospective study on the effect of general anesthesia compared with regional anesthesia and sedation” by Jason L. Koh

ConclusionPatients in the beach chair position treated with regional anesthesia and sedation had almost no cerebral desaturation events, unlike patients who had general anesthesia. Avoidance of general anesthesia in the beach chair position may reduce the risk of ischemic neurologic injury.

Journal of Bone and Joint Surgery February 2013

“Differences in Short-Term Complications Between Spinal and General Anesthesia for Primary Total Knee Arthroplasty” by Andrew J. Pugely

ConclusionPatients undergoing total knee arthroplasty who were managed with general anesthesia had a small but significant increase in the risk of complications as compared with patients who were managed with spinal anesthesia; the difference was greatest for patients with multiple comorbidities. Surgeons who perform knee arthroplasty may consider spinal anesthesia for patients with comorbidities.

British Journal of Anesthesia August 2013

“Recovery after total intravenous general anesthesia or spinal anesthesia for total knee arthroplasty: a randomized trial”

ConclusionGeneral Anesthesia with a Propofol and Remifentanyl TIVA had a more favorable recovery effects after TKA compared with Spinal Anethesia.

BioMed Research International 2013

“Hip Fracture Surgery: Does Anesthesia Matter?” by Rizman Haroon Rashid

ConclusionEven though administration of regional anesthesia was positively correlated with shorter operative duration, the type of anesthesia was not found to affect surgical outcomes in the two study groups. Based on these results, we recommend that anesthesia should be tailored to individual patient requirements.