ANESTHESIA FOR

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ANESTHESIA FOR ORTHOPEDIC SURGERY
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Special considerations in orthopedic surgery(1)

• Bone Cement
• Polymethylmethacrylate-joint arthroplasty
• Interstices for cancellous bone and binds to
  prosthetic device to pts bone
• Polymerized powder liquid monomer ?
  polymerization cross linking
• Exothermic reaction ? hardening, expansion
• Intramedullary HTN ? 500 mmHg, embolization of
  fat, BM, cement, air
• Vasodilation, systemic vascular resistance ??
• Release of thromboplastin ? platelet aggregation
• Bone cement implantation syndrome
• Hypoxia, hypotension, dysrhythmia, pul HTN,
  cardiac output ??

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Special considerations in orthopedic surgery(2)

• Bone Cement (continued)
• Prevention of embolism (?? femoral prosthesis)
• Increasing inspired oxygen concentration prior to
  cementing
• Maintaining euvolemia, creating a vent hole in
  the distal femur, performing high-pr lavage of
  the femoral shaft, uncemented femoral component
• Cementless implant ? loosening ??, ?? ?? ?? ???
  

4
Special considerations in orthopedic surgery(3)

• Pneumatic Tourniquets
• Bloodless field, facilitate surgery
• Potential problems hemodynamic change, pain,
  metabolic alterations, arterial thromboembolism,
  pul. embolism
• Inflation pr 100 mmHg over systolic blood pr
• 2?? ?? ?? ?, ???? muscle dysfunction, permanent
  pph. n inj
• Bilateral lower ext. tourniquet ? shift of blood
  volume into central circulation
• Tourniquet pain ? increasing mean arterial blood
  pr,, progressive sympathetic activation
• Deflation of the cuff ? significant fall in
  central venous pr arterial blood pr
• Washout of accumulated metabolic wastes of the
  ischemic ext
• PaCO2, ETCO2, serum lactate potassium ??
• increase in minute ventilation, dysrhythmia

5
Special considerations in orthopedic surgery(4)

• Pneumatic tourniquet (continued)
• Deflation ? ischemic area ? lipid peroxide ??
• Deep vein thrombosis
• D/t tourniquet induced ischemia
• Transesophageal echocardiography
• C/I of pneumatic tourniquet
• Calcific arterial disease

6
Special considerations in orthopedic surgery(5)

• Fat Embolism syndrome
• Less frequent but potentially fatal (10-20
  mortality)
• Long-bone Fx, pelvic Fx ? 72 ?? ? ??
• Sx triad dyspnea, confusion, petechiae
• CPR, parenteral feeding with lipid infusion,
  liposuction
• Increased free fatty acid level ? toxic effect on
  the capillary-alveolar membrane ? vasoactive
  amines, PG release ? development of acute
  respiratory distress syndrome
• Dx petechiae on the chest, upper ext, axillae,
  conjunctiva
• C/M coagulation abnormality, ETCO2 ??, arterial
  oxygen saturation ??, pul a pr ??
• Treatment
• Early stabilization of the fracture
• Oxygen therapy, continuous positive airway pr

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Special considerations in orthopedic surgery(6)

• Deep Venous Thrombosis Thromboembolism
• DVT pul embolism ?major cause of morbidity, and
  mortality
• Risk factor obesity, age gt60, 30? ???
  procedure, tourniquet ??, lower ext Fx,
  immobilization for more than 4 days
• Incidence of clinically significant pulmonary
  embolism ? high as 20, fatal pul. Embolism, 1-3
  
• Prophylactic treatment anticoagulation and use
  of intermittent pneumatic compression
• High risk pt heparin 5000 U / every 8h, IPC,
  warfarin, LMWH
• Neuraxial anesthesia alone or combined with
  general anesthesia
• Reduce thromboembolic complications
• Sympathectomy induced increase in low-ext venous
  blood flow
• Systemic anti-inflammatory effects on local
  anesthetics
• Decrease plt reactivity

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HIP SURGERY-FRACTURE OF THE HIP

• Preoperative Considerations
• ???? ??? elderly, frail
• Concomitant disease coronary a disease, cerebral
  vascular disease, COPD ?
• Frequently dehydrated ? poor oral intake
• Occult blood loss ? extracapsular type (base,
  intertrochanteric,subtrochanteric)? intracapsular
  type (subcapital,transcervical) ? ?? bleeding ?
  ??
• Frequent presence of preoperative hypoxia? fat
  embolism, bed rest ? ?? atelectasis, CHF

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HIP SURGERY-FRACTURE OF THE HIP (continued)

• Intraoperative Management
• Regional VS general anesthesia
• Early postoperative periods regional anesthesia
  Pt ? mortality ? ??? decrease in thromboembolic
  disease
• 2?? ? mortality ? ???
• Post op delirium and cognitive impairment
  regional ? ? ??
• Spinal anesthesia hypobaric technique ? easier
  positioning
• Fx site, displacement ??, functional status of
  Pt, surgeons preference ? ?? ?? ?? ?? ??? ???
• Hemiarthroplasty and total hip replacement
• More longer, invasive operations
• Greater blood loss hemodynamic change
• Direct arterial pr monitoring, large-bore venous
  access ??

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HIP SURGERY-TOTAL HIP ARTHROPLASTY(1)

• Preoperative Considerations
• Osteoarthritis, rheumatoid arthritis,
  osteonecrosis ?? indication
• OA degenerative disease affecting the articular
  surface
• Spine involve ???? ??, intubation ? neck
  positioning ? gentle ?? ??
• RA OA ? ??? (immune disease, systemic disease,
  multiple joint involve, severe deformity ? ?? ?
  ??
• ??? ?? ?? ????? ????, coronary artery disease ?
  ??? masking ? dipyridamole thallium scan,
  dobutamine echo ??
• ?? ??, cervical spine, TM, joint, atlantoaxial
  involvement ?? ?? radiological evaluation
• Atlantoaxial subluxation ? intubation ? odontoid
  process ? foramen magnum ?? ?? ?? vertebral flow,
  spinal cord, brain stem ?? ?? ? ???? ??

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HIP SURGERY-TOTAL HIP ARTHROPLASTY(2)

• Preoperative Considerations (continued)
• ?? RA ???? ?? ? flexion, extension lateral
  radiographs ? evaluation ? severe case ? ?? FOB
  ??
• Hoarseness inspiratory stridor ? narrowing of
  the glottic opening

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HIP SURGERY-TOTAL HIP ARTHROPLASTY(3)

• Intraoperative Management
• Positioning ?? lateral decubitus position
• Several surgical step
• Dislocation removal of femoral head
• Reaming of the acetabulum
• Insertion of a prosthetic acetabular cup
• Reaming of the femur insertion of a femoral
  component
• 3 potential life-threatening complication
• Bone cement implantation syndrome
• Intra-, and post-operative hemorrhage
• Venous thromboembolism
• Embolic phenomena ?? femoral prosthesis
  insertion ? ? ??

13
HIP SURGERY-TOTAL HIP ARTHROPLASTY(4)

• Bilateral Arthroplasties
• First femoral component insertion ?, pul embolism
  ? ???, ?? ? ? ??
• Pulmonary vascular resistance ? ?? ? signals of
  embolization
• PVR PA-PAOP/cardiac output X 80
• ?? pulmonary artery pr ? ?????? ????
  contralateral surgery ? ?? ??? ?
• Revision Arthroplasty
• Significant blood loss
• Controlled hypotension ? decrease intraoperative
  bleeding, prosthetic cementing ? ?? ??, ?? ?? ??
• Regional anesthesia ? ?? ??? mean ABP ??? G/A ?
  ?? ? ?? bleeding
• Preoperative blood donation, intraoperative blood
  salvage, high dose aprotinin, preoperative
  recombinant EPO ?? ????? ?

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HIP SURGERY-TOTAL HIP ARTHROPLASTY(5)

• Minimally invasive arthroplasty
• CAS computer-assisted surgery ? facilitate
  minimally invasive techniques
• Tracking device ? target bone ? ?? ? optical
  camera ? infrared diode ? ?? ??? sense
• CAS ? very accurate and optimal placement of
  implants
• Reduce hospitalization to 24h or less
• Epidural anesthesia with a propofol infusion
  LMA
• No parenteral opioids needs
• Premedication with multimodal analgesia
• Oxycodone 10mg, valdecoxib 20mg, acetaminophen
  500mg PO MDZ 1-2 mg

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HIP SURGERY-CLOSED REDUCTION HIP DISLOCATION

• Primary hip arthroplasty ? 3, total hip revision
  ? 20 incidence
• CAS ?? ? incidence ??
• Flexion gt90?, internal rotation gt20, adduction
  gt20
• Increase the risk of dislocation
• ??? closed reduction ?? ?? ??
• G/A with a face mask, LMA
• ??? ?? succinylcholine, mivacurium ?? NMBA ??

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KNEE SURGERY-KNEE ARTHROSCOPY

• Preoperative Consideration
• Arthroscopy Surgery of main joint
• ?? outpatient procedure ? healthy young patient
  ? ??
• Knee arthroscopy ? ??, ?? ??? ?? ?? ??? ??
• Intraoperative Management
• Tourniquet ? ??? bloodless field
• ??? G/A ???, supine position ?? ??
• ?? ?? LMA ??
• Neuraxial blockade ? three-in-one femoral nerve
  and lateral femoral cutaneous nerve block ?? ??
• Postoperative Pain Relief ? early ambulation, ???
  ????, minimal N/V
• Avoid large doses of systemic opioids
• Intraarticular bupivacaine
• Systemic ketorolac, intraarticular steroids,
  three-in-one nerve block

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KNEE SURGERY-TOTAL KNEE REPLACEMENT

• Preoperative Consideration
• OA, RA
• Intraoperative Management
• THR ? ?? ?? ?? ??
• Supine position, less blood loss
• Cooperative Pt ? tolerate a regional technic with
  iv sedation
• Bone cement use ? bone cement implantation
  syndrome ? THR ? ?? ??
• Preoperative placement of an epidural catheter ?
  ? ? ?? ??? ??, minimal motor blockade for 48-72 h
• Indwelling femoral sheath catheter ? good
  analgesia minimal motor blockade ? ? ?? ??
  (48h), fewer side effect than epidural analgesia

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KNEE SURGERY-TOTAL KNEE REPLACEMENT
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SURGERY ON THE UPPER EXTREMITY

• Shoulder Surgery
• Beach chair position
• Interscalene technique of BPB is ideally suited
• G/A ?? ? ??, post-op pain control ? ????? ??
• G/A ?? ?, intense muscle relaxation ??? ?
• Indwelling interscalene catheter
• Postoperative analgesia for 48 h

20
HAND SURGERY

• Carpal tunnel release
• One of most common operations in anesthetic
  practice
• Intravenous regional anesthesia, Bier block ?
  ideally suited
• Short-acting anesthetics (propofol and
  desflurane) with LMA
• 1?? ?? ???? ?? ?, BPB ??
• Axillary approach below the elbow