anesthesia for orthopaedic replacement surgeries prof.dr.k.balakrishnan,chennai
TRANSCRIPT
Anesthesia for Anesthesia for orthopaedic replacement orthopaedic replacement surgeriessurgeries
Prof.Dr.K.BALAKRISHNAN,Prof.Dr.K.BALAKRISHNAN,Chennai.Chennai.
Introduction
Some of the common joint replacement surgeries are 1. Hip replacement 2. Knee replacement3. Shoulder replacement4. Elbow replacement
Total knee replacement (TKR) Total knee replacement (TKR) and hip fracture coming for and hip fracture coming for replacement are the two most replacement are the two most common surgical procedures common surgical procedures after the sixth decade of life.after the sixth decade of life.
Most of the patients have Most of the patients have degenerative joint disease, degenerative joint disease, commonly osteoarthritis (OA).commonly osteoarthritis (OA).
Other conditions requiring Other conditions requiring knee or hip replacement are knee or hip replacement are injury to the neck of femur or injury to the neck of femur or knee joint, knee deformity, knee joint, knee deformity, rheumatoid arthritis and rheumatoid arthritis and gout.gout.
Joint replacement is Joint replacement is performed to relieve pain and performed to relieve pain and morbidity.morbidity.
The challenge….The challenge….
Decreased organ function and Decreased organ function and reservereserve
Co-morbid conditionsCo-morbid conditions Consequences of Consequences of
polypharmacypolypharmacy
Challenges have been Challenges have been converted into good converted into good outcomes…outcomes… Better understanding on Better understanding on
pathophysiology of agingpathophysiology of aging Better pharmacotherapyBetter pharmacotherapy Safer anaesthetic techniquesSafer anaesthetic techniques Improvements in monitoringImprovements in monitoring Multimodal analgesia and site Multimodal analgesia and site
specific analgesiaspecific analgesia Physiotherapy and early Physiotherapy and early
ambulationambulation
Pain is the first enemy Pain is the first enemy to mankind….to mankind….
And anaesthesiologists are
mankind’s guardian angels.
The straw that breaks the camel’s back may be a very small one when the camel is
nearing the end of it’s journey !
Pre-operative concernsPre-operative concerns
Associated injuriesAssociated injuries Cause for the fallCause for the fall Difficulty in assessing cardio Difficulty in assessing cardio
respiratory reserverespiratory reserve Osteoarthritis- Medications-Osteoarthritis- Medications-
NSAIDsNSAIDs
Pre-operative Pre-operative concerns….concerns….
Pre-renal azotaemiaPre-renal azotaemia DVT prophylaxisDVT prophylaxis Diabetes MellitusDiabetes Mellitus The emotional significance of The emotional significance of
fracture to the geriatric patient fracture to the geriatric patient must also be considered.must also be considered.
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.
Echocardio graphy 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.
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 .
Intra-operative Intra-operative concernsconcerns
RegionalRegional
General anesthesiaGeneral anesthesia
The choice of anaesthesia is determined by:
i) surgical factorsii) Patients factorsiii) Estimates of risk associated
with anaesthesia techniques
Regional Anesthesia -Regional Anesthesia -AdvantagesAdvantages Stress response to surgeryStress response to surgery Intraoperative blood lossIntraoperative blood loss Post-operative hypoxiaPost-operative hypoxia PONVPONV DVT- early mobilizationDVT- early mobilization
Regional Anesthesia -Regional Anesthesia -AdvantagesAdvantages
Preemptive analgesiaPreemptive analgesia Post-operative analgesiaPost-operative analgesia
Hypostatic pneumonia
Pressure sores
Centri Neuraxis Block - Concerns
•Coagulopathy
•Conscious sedation
•Shivering
•Technical difficulty
Autonomic dysfunction-Hypotension
•I.V. fluids, •vasopressors, Diastolic pressure 60 mm Hg
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).
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.
General anesthesia General anesthesia -Pre-operative beta -Pre-operative beta
blockadeblockade CADCAD HypertensionHypertension Diabetes mellitusDiabetes mellitus HypercholesterolemiaHypercholesterolemia Renal dysfunctionRenal dysfunction Goal: Heart rate between 60-Goal: Heart rate between 60-
70.70.
General anesthesia General anesthesia -Pre-Oxygenation-Pre-Oxygenation
100% Oxygen100% Oxygen 8 deep breaths8 deep breaths Oxygen flow 10 L per minOxygen flow 10 L per min
General anesthesia General anesthesia -Choice of Anesthetic -Choice of Anesthetic
agentagentShort acting and less lipid soluble drugsShort acting and less lipid soluble drugs
• PropofolPropofol• Fentanyl Fentanyl • RocuroniuRocuroniu
mm• AtracuriumAtracurium• SevofluraneSevoflurane• IsofluraneIsoflurane
Intra-operative Intra-operative monitoringmonitoring
Pulse OximetryPulse Oximetry 5 lead ECG-ST analysis5 lead ECG-ST analysis CapnographyCapnography NIBP- IBPNIBP- IBP TemperatureTemperature Neuromuscular Neuromuscular
monitoringmonitoring Urine outputUrine output
Blood TransfusionBlood Transfusion
Progressive reaming of femur and resection of the condyles is associated with steady blood loss
Bone Cement- Bone Cement- HypotensionHypotension
The placement of the prosthesis involve the use of methylmethacrylate ( bone cement )
The cementing can cause hemodynamic fluctuations
These fluctuations are related to the vasodilatory and mast-cell degranulating properties of the monomeric form of methylmethacrylate
Bone Cement Bone Cement implantation syndromeimplantation 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.
Bone Cement Bone Cement implantation syndrome implantation syndrome - Treatment- 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.
Fat embolism
The high incidence of fat embolism with femoral neck fracture repair and cemented endoprosthesis may contribute to pulmonary dysfunction
Tourniquet in knee replacementTourniquet inflation:i) may precipitate heart failureii) may cause hypotension after release
of tourniquet due to:a) Release of acid productsb) Affected limb getting filled with bloodc) Blood loss
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.
Post-operative care Post-operative care
Post-operative concernsPost-operative concerns
Pain Pain
Pain Pain
PaiPain n Pain Pain
Pain Pain
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.
No.1: Start with low doseAvoid 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
PRINCIPLES
Post-operative concernsPost-operative concerns
• Post operative delirium
• Post operative hypoxemia
• Hyponatremia
• Hypoglycemia
Peri-operative Sepsis
Peri- operative Antibiotics
Early Mobilisation
Psychological support
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.