Anesthesia for orthopaedic replacement surgeries

1
Anesthesia for orthopaedic replacement surgeries
Prof.Dr.K.BALAKRISHNAN, Chennai.
2
Introduction

• Some of the common joint replacement surgeries
  are
• 1. Hip replacement
• 2. Knee replacement
• 3. Shoulder replacement
• 4. Elbow replacement

3
(No Transcript)
4
(No Transcript)
5

• Total knee replacement (TKR) and hip fracture
  coming for replacement are the two most common
  surgical procedures after the sixth decade of
  life.

6

• Most of the patients have degenerative joint
  disease, commonly osteoarthritis (OA).

7

• Other conditions requiring knee or hip
  replacement are injury to the neck of femur or
  knee joint, knee deformity, rheumatoid arthritis
  and gout.

8

• Joint replacement is performed to relieve pain
  and morbidity.

9
The challenge.

• Decreased organ function and reserve
• Co-morbid conditions
• Consequences of polypharmacy

10
(No Transcript)
11
Challenges have been converted into good outcomes

• Better understanding on pathophysiology of aging
• Better pharmacotherapy
• Safer anaesthetic techniques
• Improvements in monitoring
• Multimodal analgesia and site specific analgesia
• Physiotherapy and early ambulation

12
Pain is the first enemy to mankind.
And anaesthesiologists are mankinds
guardian angels.
13
The straw that breaks the camels back may be a
very small one when the camel is nearing the end
of its journey !
14
Pre-operative concerns

• Associated injuries
• Cause for the fall
• Difficulty in assessing cardio respiratory
  reserve
• Osteoarthritis- Medications-NSAIDs

15
Pre-operative concerns.

• Pre-renal azotaemia
• DVT prophylaxis
• Diabetes Mellitus
• The emotional significance of fracture to the
  geriatric patient must also be considered.

16
Preoperative Preparation

• Evaluation of the functional cardiovascular
  reserves may be difficult due to the bedridden
  state, the confusion encountered, and the
  fracture. Simple steps (e.g., auscultation, ECG,
  and chest x-ray) can detect acute decompensation.

17

• Echocardiography if feasible at the bedside and
  can give useful information about left
  ventricular and valvular function.
• Evaluation of electrolytes and blood count is
  required anemia or electrolyte disturbances
  should be addressed prior to anesthesia
  induction.

18
Prophylaxis against DVT

• Prophylaxis against deep vein thrombosis after
  lowerlimb joint surgery is done with low
  molecular weight heparin starting either post
  operatively or 12 hours preoperatively .

19
Intra-operative concerns

• Regional

?
General anesthesia
20

• The choice of anaesthesia is determined by
• i) surgical factors
• ii) Patients factors
• iii) Estimates of risk associated with
  anaesthesia techniques

21
Regional Anesthesia -Advantages

• Stress response to surgery
• Intraoperative blood loss
• Post-operative hypoxia
• PONV
• DVT- early mobilization

22
Regional Anesthesia -Advantages

• Preemptive analgesia
• Post-operative analgesia

Hypostatic pneumonia Pressure sores
23
Centri Neuraxis Block - Concerns

• Coagulopathy
• Conscious sedation
• Shivering
• Technical difficulty

• Autonomic dysfunction
• -Hypotension
• I.V. fluids,
• vasopressors,
• Diastolic pressure 60 mm Hg

24
Regional anesthesia techniques

• - Spinal
• - Epidural anesthesia
• - Combined spinal epidural anaesthesia
• - Femoral and Sciatic nerve blocks (especially
  in patients with fixed cardiac output in whom a
  neuraxial block is not preferred due to possible
  haemodynamic changes specifically profound
  hypotension).

25

• The alternative option in fixed cardiac output
  states include segmental epidural, here the
  titrated doses of local anaesthetic
  administration and just blocking the segments
  involved offers the benefits of regional
  anaesthesia in critically ill patients and at the
  same time provides stable haemodynamics.

26
General anesthesia -Pre-operative beta
blockade

• CAD
• Hypertension
• Diabetes mellitus
• Hypercholesterolemia
• Renal dysfunction
• Goal Heart rate between 60-70.

27
General anesthesia -Pre-Oxygenation

• 100 Oxygen
• 8 deep breaths
• Oxygen flow 10 L per min

28
General anesthesia -Choice of Anesthetic agent

• Short acting and less lipid soluble drugs

• Propofol
• Fentanyl
• Rocuronium
• Atracurium
• Sevoflurane
• Isoflurane

29
Intra-operative monitoring

• Pulse Oximetry
• 5 lead ECG-ST analysis
• Capnography
• NIBP- IBP
• Temperature
• Neuromuscular monitoring
• Urine output

30
Blood Transfusion
Progressive reaming of femur and resection of the
condyles is associated with steady blood loss
31
Bone Cement- Hypotension
The placement of the prosthesis involve the use
of methylmethacrylate ( bone cement )
32

• The cementing can cause hemodynamic fluctuations
• These fluctuations are related to the
  vasodilatory and mast-cell degranulating
  properties of the monomeric form of
  methylmethacrylate

33
Bone Cement implantation syndrome
Bone cement implantation syndrome (BCIS) is
poorly understood. It is an important cause of
intraoperative mortality and morbidity in
patients undergoing cemented hip arthroplasty and
may also be seen in the postoperative period in a
milder form causing hypoxia and confusion.
34
Bone Cement implantation syndrome - Treatment
BCIS may be reversible with prompt basic life
support and treatment to maintain both coronary
perfusion pressure and right heart function.
Administer fluid volumes to augment right
ventricular preload. Direct acting vasopressors,
such as phenylephrine and norepinephrine can be
titrated to restore adequate aortic perfusion To
improve ventricular contractility and function
administer inotropes such as dobutamine.
35
Fat embolism

• The high incidence of fat embolism with femoral
  neck fracture repair and cemented endoprosthesis
  may contribute to pulmonary dysfunction

36
Tourniquet in knee replacement

• Tourniquet inflation
• may precipitate heart failure
• may cause hypotension after release of tourniquet
  
• due to
• Release of acid products
• Affected limb getting filled with blood
• Blood loss

37
Post-operative care

• Immediate postoperative care should be directed
  to supporting oxygenation, controlling pain, and
  facilitating the patient's return to the baseline
  mental status by emphasizing orientation.

38
Post-operative concerns
39

• Postoperative pain therapy is best a multimodal
  approach.
• - local anaesthetic infusions through perineural
  catheters supplemented with analgesics including
  a combination of paracetamol, tramadol,
  NSAID(when there is no contraindication) and
  opioids.

40
PRINCIPLES
No.1 Start with low dose Avoid long acting
drugs   No.2 Use standing dose
regimens   No.3 Repeated reassessment of pain
relief   No.4 Repeated reassessment of side
effects   No.5 Educate/inspire the care giver
41
Post-operative concerns

• Post operative delirium
• Post operative hypoxemia
• Hyponatremia
• Hypoglycemia

42
Early Mobilisation
Psychological support
Peri-operative Sepsis
Peri- operative Antibiotics
43
Conclusion

• Geriatric patients for joint replacement
  surgeries offer a great challenge to the
  anaesthesiologists.
• A careful preoperative examination, preoperative
  optimization, safe intraoperative anaesthetic
  techniques, good postoperative pain relief, good
  postoperative followup with rehabilitation would
  aid in decreasing the morbidity in these patients.

44
(No Transcript)
45
Thank you