Anesthesia for Orthopedic Surgery

1
Anesthesia for Orthopedic Surgery

• DENNIS STEVENS CRNA,MSN,ARNP
• February 2006
• Anesthesiology Nursing Program
• Florida International University

2
Special Acknowledgement

• The following lecture prepared and organized by
• Gerard T. Hogan DNSc, CRNA, ARNP
• Program Director
• School of Nursing Anesthesiology
• Florida International University

3
Anesthesia for Orthopedic Surgery

• Tourniquets
• Virtually bloodless field highly desirable
• Width should cover 50 of target extremity
• Padding such as stockinette or webril
• Avoid wrinkles in padding
• Overlap of cuff should be opposite of
  neurovascular bundle
• Inflation pressure usually 100mmHg greater than
  systolic blood pressure

4
Anesthesia for Orthopedic Surgery

• Tourniquets
• Inflation pressures
• Should not exceed 300mmHg in upper extremities
• Should not exceed 500 mmHg in lower extremities
• Exsanguination important before inflation
• Elevation or Esmarch bandage

5
Anesthesia for Orthopedic Surgery

• Tourniquet pain
• Compression of Intraneural 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
• Treatment options

6
Anesthesia for Orthopedic Surgery
7
Anesthesia for Orthopedic Surgery

• Tourniquet Safety
• Always place where nerves are best protected in
  the musculature
• Check proper function of machine
• Never inflate for longer than 2 hours
• 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
• Always chart times on your record

8
Anesthesia for Orthopedic Surgery

• Hip Surgery
• ORIF Open Reduction with Internal fixation
• Done for fractures
• Often uses fracture table
• Expect frail and elderly
• Frequent concomitant disease processes
• Diabetes
• CAD
• High Risk Populations

9
Anesthesia for Orthopedic Surgery

• Hip Surgery
• ORIF
• Frequently dehydrated
• Occult blood loss can be significant
• Intracapsular
• Subcapital, transcervical less blood loss
• Extracapsular
• Femoral neck, intertrochanteric, subtrochanteric
  expect higher blood loss

10
Anesthesia for Orthopedic Surgery
11
Anesthesia for Orthopedic Surgery

• Hip Surgery
• Fat Embolism
• Occurs to some degree in all hip fx patients
• Fat Embolism Syndrome
• Presents within 72 hours
• Long bone, hip, or pelvic fractures
• 3 hallmark signs
• Confusion
• Dyspnea
• Petechiae

12
Anesthesia for Orthopedic Surgery

• Hip Surgery
• Fat Embolism
• Fat globules released into the blood through
  tears in medullary vessels
• Theory that they are chylomicrons resulting from
  aggregation of circulating fatty acids
• Thrombocytopenia and prolonged clotting times may
  occur

13
Anesthesia for Orthopedic Surgery

• 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

14
Anesthesia for Orthopedic Surgery

• General or Regional?
• Extensively evaluated
• Regional has lower mortality in the first 2
  months post surgery
• No significant difference in mortality after 2
  months
• Regional associated with thromboembolic events
  more than General
• Morbidity post GA is higher immediately post
  operatively

15
Anesthesia for Orthopedic Surgery

• Hip Surgery
• Total Hip Arthroplasty
• Lateral decubitis position
• Higher degree of visibility and range of motion
• Most common indication is Osteoarthritis (OA)
• Also called Degenerative Joint Disease (DJD)
• Large incision with invasion of major muscle
  groups
• Femoral head is very vascular

16
Anesthesia for Orthopedic Surgery

• Hip Surgery
• Total Hip Arthroplasty
• Acetabulum very vascular as well
• Resection of femoral head
• Reaming of femoral shaft
• Three life threatening complications
• Bone cement implantation syndrome
• Perioperative hemorrhage
• Thromboembolism

17
Anesthesia for Orthopedic Surgery

• Hip Surgery
• Total Hip Arthroplasty
• Bone Cement Implantation Syndrome
• Methylmethacrylate
• Mixing Powder and liquid causes exothermic
  reaction
• Reaction causes expansion of cement and forces
  fat, blood, and air into the femoral venous
  channels
• Residual Monomer (liquid) is a potent vasodilator
• Release of tissue thromboplastin may trigger
  thromboembolism and cause instability

18
Anesthesia for Orthopedic Surgery

• Hip Surgery
• Closed reduction of the hip
• May be necessary if prosthesis comes out of the
  socket
• Often done with heavy MAC unless contraindicated
• May proceed to open if unable to reduce closed,
  so be prepared for GA
• Extremes of flexion and internal rotation can
  dislocate a new prosthesis use abduction pillow
  before transfer to bed

19
Anesthesia for Orthopedic Surgery

• Lateral Decubitis
• Thoracic, renal, and orthopedic procedures
• Presents unique challenges to the anesthetist
• Importance of body alignment
• Use of
• Bean Bag
• Axillary Roll
• Pillows
• Sandbags
• Mayo stand

20
Anesthesia for Orthopedic Surgery

• Lateral Decubitis (cont.)
• Cardiovascular Considerations
• Respiratory Considerations
• FRC decreased
• Ventilation/Perfusion mismatch
• Atelectasis
• Use of PEEP
• Special Considerations

21
Anesthesia for Orthopedic Surgery
22
Anesthesia for Orthopedic Surgery

• Knee Surgery
• Arthroscopy
• LMA vs ETT
• Tourniquet concerns
• Spontaneous respiration
• Calcific arterial disease
• Deep Vein Thrombosis
• Intraarticular medication injection

23
Anesthesia for Orthopedic Surgery

• Total Knee Arthroplasty
• Rheumatoid or Osteoarthritis
• Supine position
• Regional vs. general anesthesia
• Cement implantation syndrome
• Tourniquet concerns
• Autologous blood donation
• Bleeding is usually an issue post op

24
Anesthesia for Orthopedic Surgery

• Spinal Surgery
• Concerns about prone position
• Intraoperative blood loss
• Large incisions and fluid shifts
• Most common indication is disc herniation or
  spinal stenosis
• Goal is symptomatic relief and stabilization

25
Anesthesia for Orthopedic Surgery
26
Anesthesia for Orthopedic Surgery
27
Anesthesia for Orthopedic Surgery

• Scoliosis
• Lateral curvature of the spine
• 75-80 of cases are idiopatic
• Untreated can lead to complex deformity
• SSEP monitoring
• Preoperative evaluation
• PFTs, ABGs, EKG
• Increased incidence of MH if caused by Muscular
  dystrophy

28
Anesthesia for Orthopedic Surgery

• Scoliosis
• Large blood loss
• Wake up test
• Severe respiratory disease may be left intubated
  postoperatively
• Major concerns with positioning
• Posterior, anterior, or thoracoabdominal
• May require double lumen tube

29
Anesthesia for Orthopedic Surgery

• Foot and Ankle Surgery
• Ankle fracture
• Plate and screws
• Bunionectomy
• Hammer toe correction
• Plantar fasciotomy
• Achilles tendon repair

30
Anesthesia for Orthopedic Surgery

• Ankle Block
• Frequently used in podiatric cases
• Insert needle lateral to the posterior tibial
  artery at the superior aspect of the medial
  malleolus (posterior tibial nerve)
• Inject 5ml of local and 2ml as you withdraw the
  needle
• Insert needle at the lateral border of the
  achilles tendon with the line between the
  malleoli, advance toward the lateral condyle,
  inject 5ml of local (sural nerve)

31
Anesthesia for Orthopedic Surgery
32
Anesthesia for Orthopedic Surgery
33
Anesthesia for Orthopedic Surgery

• Ankle Block
• Draw a line between the superior edge of the
  medial malleolus across the anterior portion of
  the ankle
• Flex the foot and place the needle between the
  tendons medial to the big toe (deep peroneal
  nerve), inject 5ml of local
• With the remaining local, fan inject across the
  same plane across the ankle (saphenous nerve)

34
Anesthesia for Orthopedic Surgery
35
Anesthesia for Orthopedic Surgery
36
Anesthesia for Orthopedic Surgery

• Upper Extremity
• Shoulder arthroplasty or arthroscopy
• Frequently sitting position
• Venous air embolism precautions
• Airway concerns
• Elbow arthroplasty or arthroscopy
• Prone position
• Turn head away from field
• Turn table 90 degrees

37
Anesthesia for Orthopedic Surgery

• Hand surgery
• General vs. regional
• Bier block
• Axillary block
• Wrist block
• Touniquet concerns
• Long cases
• Often awake, often uncomfortable