PROBLEMS DURING ORTHOPAEDIC SURGERY

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PROBLEMS DURING ORTHOPAEDIC SURGERY

• Dr. M.J. MAHANTHESHA SHARMA
• M.D., D.A.,
• PROFESSOR
• DEPARTMENT OF ANAESTHESIA
• J.J.M .MEDICAL COLLEGE
• DAVANGERE 577 004.

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PROBLEMS DURING ORTHOPAEDIC SURGERY

• Air way problems
• Positioning related problems
• Blood loss related problems
• Bradycardia / Asystole
• Paraplegia during scoliosis surgery
• Neuropraxia
• DVT problem
• Thromboembolism problems
• Fat embolism
• Bone cement related problems
• Anticoagulation therapy
• Tourniquet problems
• Postoperative delirium and confusion

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AIRWAY PROBLEMS

• Complex airway challenges are common
• Juvenile rheumatoid arthritis, ankylosing
  spondylitis, prior cervical fusion.
• Impossible to intubate with conventional
  laryngoscopy.
• Failed intubation, trauma to airway, respiratory
  distress after extubation.

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PROBLEMS

• Rheumatoid arthritis C1-2 subluxation
  instability Uncontrolled flexion compromise the
  spinal cord.
• Uncontrolled flexion during spinal
  surgery-quadriplegia.
• Athletic patients coming for sport related
  surgery
• - Acute respiratory distress after
  extubation.
• - Low pressure pulmonary edema.
• Cricoarytenoid joints decreases the glottic
  area.
• Intrinsic and extrinsic airway diseases - PFT.

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PREVENTION MANAGEMENT

• Careful assessment of the airway
• Selection of regional technique
• Select fibroptic technique under light sedation.
• Careful positioning them for surgery.
• If GA is required use fibroptic bronchoscope.
• Check neurological functions
• Acute respiratory distress after extubation
  prevented by
• Fibroptic intubation
• Kept intubated 4-5 hours, head elevation 30.
• Use smaller endotracheal tubes.

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POSITION RELATED PROBLEMS

• Requires different intraoperative positions.
• Limbs are placed in unphysiological positions.
• Pressure sores pressure effect.
• Nerve injury - compression or stretch.
• Ischaemia vascular kink or obstruction.
• Ischaemia or compartment syndrome results.
• Avoid active movement of Ankylosed joint.

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SPECIFIC PROBLEMS DUE TO POSITIONING

• THR (dependent limb) compartment syndrome.
• Spinal surgery - prone - Brachial plexus palsy
• Prone - compression - femoral or lateral
  cutaneous nerves.
• Prone compression of eye Post op. blindness.
• Brachial plexus stretch Palsy - shoulder
  arthroplasty.

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PREVENTION

• Correct positioning, proper padding.
• Avoid compression on eye.
• Avoid unnecessary stretching of the limbs.
• Avoid tight bandages and cast.
• Care of abduction braces after shoulder surgery.

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BLOOD LOSS PROBLEMS

• Major Procedures likely to have estimated blood
  loss gt1lt to 50 of blood volume
• Revision total hip arthroplasty
• Arthroplasty for congenital hip deformity
• Removal of infected prosthesis
• Revision IM nailing of a femur fracture
• Resection and reconstruction of bone lesions
• Bilateral total knee arthroplastis
• Biopsy of any sacral lesion
• Spinal fusion at more than three levels.

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Hypotension

• Main complication of blood loss
• Induced hypotensive technique
• Monitor intra op. SV and filling pressure.
• Homologous transfusion
• Intraoperative cell saver.
• Preoperative autologus blood donation.
• Invasive monitor arterial pressure, CVP.
• Preoperative haematocrit value.

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Treatment of hypotension

• Maintain haematocrit level
• Volume replaced by
• Crystalloids
• Colloids
• Blood and blood products.
• Vesopressor
• Administration of fluids by CVP.
• Dont overload in high risk patients.

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Bradycardia/ Asystole

• GA with vacuoronium / fentanyl combination.
• Regional severe acute bradycardia.
• Common life threatening during regional.
• Block above T4 decrease heart rate.
• Needs beta agonists or atropine.
• Bezold-Jarisch type of reflex even below T6
  block.
• Vagal mediated leads to asystole.
• Triggered by reduction in intrathoracic volume.
• Shoulder surgery - sitting - venous pooling ? ?
  volume.

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Management

• Rapid treatment is required.
• Some times death or permanent brain damage.
• Proper vigilance
• Maintain adequate blood volume with IV fluids
• Prophylactic administration of atropine, beta
  agonists.
• Treat with epidrine 10-20mg, atropine 0.4 0.8
  mg.
• Asystole treated by epinephrine, chest
  compression,

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Paraplegia and scoliosis surgery

• Tragedy, uncommon in uncomplicated cases.
• Congenital scoliosis and more severe thoracic
  curves.
• Spinal cord function monitor - SSEP and wakeup
  test.
• Hypotensive anaesthesia with MAP 60 mm of Hg.
• Facilitate optimal blood flow to spinal cord.
• Stable blood volume with CVP and urine output.
• Avoid massive blood loss.
• Care during spinal distraction.
• Maintain stable circulation.
• Invasive monitoring as and required.
• Blood transfusion as and required.

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Neuropraxia

• Postoperative nerve injuries are common.
• Neuropathy, surgical injury, malpositioning or
  tourniquet.
• Prevention
• Avoid malpositioning, tight bandages or casts.
• Avoid compartment syndrome.
• Perioperative neuropraxia - anaesthesiologists
  concern.
• Legally shared the responsibility with surgeon.
• Medico legal problems are common.
• Preoperative nerve function assessment documented.

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DVT PROBLEMS

• Complications of lower extremity surgeries.
• Fatal PE is 1-2 without thrombosis prophylaxis.
• Major trauma 58 of DVT, 15 proximal veins.
• With prophylaxis DVT reduced to 20.
• Fatal PE almost minimal or eliminated.
• 15 of all postoperative deaths due to PE.

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Thromboembolism

• Hip and knee surgeries
• Advanced age and Female sex
• Previous history of thromboembolic disease
• Malignant diseases
• Prolonged bed rest / immobilization
• General anaesthesia increased incidence.
• Surgical or accidental trauma.
• Fracture of femur and tibia high risk.

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Pulmonary embolism

• PE is not a disease, complication of DVT.
• Ken Moser substantial and unacceptable.
• Lethal condition, diagnosis missed.
• Non specific symptoms and signs.
• Untreated die from future embolic episodes.
• Most of them die in first few hours.
• 80 death due to massive PE
• Prompt diagnosis and therapy - ? survival rate.
• Lower extremity and surgeries.

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Acute consequences of PE

• Acute respiratory consequences
• Increased alveolar dead space
• Pneumoconstriction
• Hypoxemia V/Q mismatch
• Hyperventilation
• Haemodynamic consequences
• Increases the pulmonary vascular resistance.
• Increase the right ventricular after load.
• Severe increased RV after load leads to RV
  failure.
• Poor cardiopulmonary status?haemodynamic
  collapse.

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Prevention

• Selection of regional anaesthesia
• Early patient mobilization
• Use pneumatic compression stockings.
• Prophylactic drug therapy (most effective one)
• Low molecular weight heparin
• Warfarrin therapy
• Heparin blood level 0.2 0.4 U/ml
• Application of vascular filters
• Monitor PT PTT screening in high risk patients.

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Management

• Thrombolytic therapy
• Urokinase
• loading dose 250,000 U IV over 30 min.
• Maintenance dose infuse 100,000 U/h IV for
  12-72hr.
• Streptokinase
• Loading dose 2000 U/kg IV over 10 min.
• Maintenance 2000 U/kg/h IV for 24 hour.
• Anticoagulant therapy
• Warfarrin for 3-6 months
• Low molecular weight heparin.
• IVC filters

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FAT EMBOLISM

• Frequency
• Frequency is estimated to be 3-4.
• Clinical diagnosis.
• Miss diagnosis due to subclinical illness.
• Mortality/Morbidity
• The mortality rate is 10-20.
• Patients with increased age
• Multiple underlying medical problems.
• Decreased physiologic reserve.
• History
• Trauma to long bone or pelvis - orthopedic
  procedures
• Parenteral lipid infusion
• Recent corticosteroid administration

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Criteria for FES
Major criteria Minor criteria
Petechiae conjunctiva, axilla PaO2 lt8kPa (60mmHg), FiO2gt0.4 CNS depression Pulmonary oedema Tachycardia gt 110 Fever (Temp. gt38.52C) Emboli on fundoscopic examination Fat in urine Fat in sputum Unexpected anemia Increased sedimentation rate Unexpected thrombocytopenia

• Diagnose FES 1 major 4 minor fat
  microglobulinemia.

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Prevention of FES

• Early rapid stabilization of fractures.
• Correction of hypovolemia.
• Drilling a small hole in the distal bone to vent
  fat.
• Use of an uncemented prosthesis for THR.
• Lavage of canal after each reaming
• Use of fluted rods during TKR.
• Modify the reaming techniques
• Corticosteroids as prophylaxis for FES.

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Management of FES

• Bronchoalveolar lavage (BAL)
• Supportive medical care
• Adequate oxygenation and ventilation
• Hemodynamic support
• Blood products if indicated
• Hydration
• Prophylaxis for DVT
• Monitoring
• Continuous pulse oximetry monitoring
• Surgical care
• Reaming or nailing the marrow
• Prophylactic placement of IVC filters

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Medical/Legal pitfalls

• CT scan - to rule out intracranial pathology.
• Search for infectious agents
• Judicious fluid replacement is required.
• FES - altered mental status, fever, hypoxia.
• Rule out life threatening disorders
• Finally diagnose FES.

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BONE CEMENT PROBLEMS

• Acute hypotension is common during THR.
• Sometimes intraoperative death also.
• Earlier due to toxic effects of methyl
  methacrylate.
• Acute hypotension - acute RVF from PE or FE.
• Insertion of long stem cemented femoral
  component.
• Common with long stem cemented revision THR.
• Treat with 10-50µg epinephrine
• Prevents outlet obstruction and cardiac arrest.
• Due to modern technique acute hypotension is
  less.

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ANTICOAGULATION PROBLEMS

• Receives drugs for prophylaxis against DVT/PE.
• Aspirin and NSIDS inhibits platelets function.
• Warfarin therapy more complex.
• Estimation of prothrombin time or INR is must.
• If PT gt2 seconds regional is not safe.
• LMWHS ? epidural haematoma.
• During insertion catheter during postop.
  analgesia.
• First RA remove catheter start LMWHS.

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TOURNIQUET

• Bloodless surgical field
• Risk of pressure related problems.
• Respond unfavourable to pneumatic.
• Anesthetist responsibility
• Adequate preoperative assessment.
• Proper size, properly fit.
• Accurate, effective pressure.
• Systolic blood pressure and cuff pressure.
• Inform surgeon ? tourniquet time.

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Tourniquet pressure

• Tourniquet pressure
• 50 100 mm of Hg above the systolic blood
  pressure.
• Upper limb 250 mm of Hg
• Lower limb 350 mm of hg
• Doppler occlusion pressure (DOP)
• Upper limb DOP 50 mm of Hg
• Lower limb DOP 75 mm of Hg Above the DOPR.
• Upper limb 135 to 255 mm of Hg
• Lower limb 175 to 305 mm of Hg

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Specification of Tourniquet

• Tourniquet time
• Initial time 90 minutes ideal is 45 60 minutes.
  
• gt2 hours deflate for 5 minutes for reperfusion.
• Width of the cuff
• Standard is 8.5 cm
• 15 cm conical shaped produces subsystolic
  pressure required to stop detectable flow.
• Ischaemic time information to surgeons
• First 2 hours half hourly intervals.
• Next at 2.5 hours.
• Next every 15 minutes interval thereafter.

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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

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NERVE INJURY

• Upper 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.

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PREVENTIVE MEASURES

• Tourniquets 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.
• Dont apply over the peroneal nerve or ulnar
  nerve.
• Avoid tourniquet to slip or twist - limb
  manipulation.
• Do not pinch or kink the connecting tubing.

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POST TOURNIQUET SYNDROME

• Postischemic 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.

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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.

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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 lt 90 minutes.

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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.

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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 patients phsyiological status.

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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.

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• 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.

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OTHER PROBLEMS

• Tourniquet 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

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POST OPERATIVE DELIRIUM / CONFUSION

• Postoperative cognitive function disturbance -
  delirium.
• Confusion state 12 to 72 hrs postop. restore 2-5
  days.
• Elderly with preoperative cognitive function
  disturbance.
• History of Parkinsons disease and alcohol
  intake.
• Delirium ? bilateral one stage TKR.
• This is not related to type of anaesthesia
• Management is difficult
• Use sedatives, Acetaminophen.

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SUMMARY CONCLUSION

• Unusual occasional and sometime fatal problems.
• Prevented by proper preoperative evaluation,
  selection of best anaesthetic technique suitable
  for the patient and particular type of surgery.
• This reduces incidence of morbidity and
  mortality.
• Whenever require institute intensive management
  to prevent death from fatal problems.

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REFERENCES

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• e-medicine Nov.9, 2007.
• Millers Anesthesia 6th Ed., 2409-2434.
• Internal Practice of Anaesthesia 2nd Ed.,
  Vol.2 114/1 to 10.
• SOA text book dtp publishing company 2006.
• John L. Atlee. Complications in Anaesthesia. 2nd
  Ed., 2007.
• Robert R. Kirby. Clinical Anaesthesia practice.
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• www.tourniquets.org J.A. McEwen December 2007.
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