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ANAESTHETIC MANAGEMENT OF
JOINT REPLACEMENT SURGERIES
DR. ARATI MOHAN BADGANDI
INTRODUCTION
 Joint replacement – common, effective procedure for relief of
disability due to severe joint pain and loss ...
Preoperative assessment
 Problems in multiple systems are common because
most patients are elderly.
 There are specific ...
Geriatric Patients
 Postmenopausal, age­associated osteoporosis ­
higher risk of fractures.
 Age­associated osteoporosis...
Osteoarthritis
 most common type of arthritis ­ loss of articular
cartilage, inflammation.
 Clinical manifestations ­ pa...
Rheumatoid Arthritis
 chronic inflammatory form of arthritis, affects about
1% of adults, prevalence 2­3 times higher in ...
 usually wrists & MCP jts are involved (distinguishes
RA from OA), boggy, tender & warm.
 may have prominent epitrochlea...
 Airway management can be challenging
› TMJ synovitis limits mandibular motion & mouth opening.
› Arthritic damage to cri...
Extra­articular manifestations of
› Restrictive pericarditis
(dyspnea, RHF, fever,
chest pain, pericardial
friction rub, p...
Ankylosing Spondylitis
 chronic inflammatory arthritic disease that results in
fusion of the axial skeleton.
 ossificati...
 Although neuraxial anesthesia is better alternative
to GA, ossification of spinal ligaments closes
intervertebral spaces...
Assessment of co-morbidities
Cardiopulmonary reserve
 estimated by assessment of exercise tolerance.
 may be impossible/...
Renal function
 may be impaired owing to age, HTN or chronic use
of NSAIDs.
Musculoskeletal
 other joint involvement is ...
Pts Excluded for Single Operation for
Bilateral Total Knee Arthroplasty
Age ≥ 75 yr
ASA class III
Active ischemic heart di...
Preoperative preparation
 Preop assessment should be carried out as above.
 Optimization of co-morbidities is required.
...
Thromboprophylaxis in Orthopedic
Surgery
 1 of leading causes of morbidity after ortho surgery.
 THR, TKR, hip and pelvi...
 As venous thrombi consist of fibrin polymers, anticoagulants
administered for the prevention and treatment of DVT.
 Thr...
 Risk factors for development of PE after surgery
1. advanced age
2. Obesity
3. previous PE and DVT
4. Cancer
5. prolonge...
 use of periop anticoagulants has significant impact on use of
RA, esp. neuraxial anesthesia (risk of an epidural hematom...
Intraoperative Management
THR
APPROACHES
 anterior / lateral approach.
 anterior approach - advantage of exposure withou...
POSITIONING
 anesthesiologist must be aware that this position may
compromise oxygenation, esp in obese and severely arth...
BLOOD LOSS
 can be significant.
 Several studies have shown controlled hypotensive epidural
anesthesia with MAP of 60 mm...
Several mechanisms suggested –
 embolization to circulation of bone marrow debris during
pressurization of femoral canal
...
TKR
TECHNIQUE
 innervation of the knee includes tibial nerve, common
peroneal nerve, posterior branch of obturator nerve,...
TOURNIQUET APPLICATION
 routinely inflated over thigh during TKA to reduce intraop
blood loss, provide a “bloodless” fiel...
 cuff should be applied over limited padding.
 Appropriate selection of tourniquet cuff size and inflation
pressure impo...
 duration of safe tourniquet inflation is unknown.
 Recommendations range from 30 min - 4 hours.
 5 min of intermittent...
 addition of narcotics to spinal or epidural anesthesia may
reduce tourniquet pain.
 After tourniquet release, MAP falls...
Anaesthetic technique
General anaesthesia:
 if general anaesthesia is indicated, bleeding may be
reduced by modest hypote...
Regional anaesthesia is technique of choice because it:
 reduce incidence of major periop complications with certain
surg...
 Sedation often desirable due to duration of operation,
intraop noise.
 Oxygen should be administered throughout the ope...
Intraoperative problems
Patient position:
 in the lateral position, there is a risk of excessive lateral
neck flexion and...
Blood loss:
 average blood loss in THR ranges from 300-1500 ml and may
double in the first 24 hours postop.
 During TKR ...
 Subsequent embolisation to the lungs produces a raised
pulmonary vascular resistance and reduction in left
ventricular r...
Fat Embolism Syndrome
 well-known complication of instrumentation of medullary
canal.
 physiologic response to fat withi...
Gurd's Diagnosis of Fat Embolism Syndrome
Major Features (at least one)   
 Respiratory insufficiency  
 Cerebral involv...
Schonfeld Fat Embolism Syndrome Index
Sign Score
 Petechial rash 5
 Diffuse alveolar infiltrates 4
 Hypoxemia Pao2<70 m...
 petechial rash is pathognomonic, usually present on
conjunctiva, oral mucosa, and skin folds of the neck
and axillae.
 ...
Deep Venous Thrombosis and Pulmonary Embolus
 VTE major cause of death after surgery or trauma
to the lower extremities.
...
Antithrombotic Prophylaxis
 LMWH started 12 hr before surgery / 12-24 hr after sx, or
4-6 hr after sx at half usual dose ...
Neueraxial Anesthesia and Analgesia in the
Orthopaedic Patient Receiving Antithrombotic Therapy
LMWH
 placement should oc...
FONDAPARINUX
 Neuraxial techniques not advised in pts who are anticipated
to receive fondarinux periop.
NONSTEROIDAL ANTI...
Postoperative Complications
Cardiac Complications
 ACC/AHA guidelines recommend preop cardiac testing in
pts at increased...
 All of these factors - stress response - tachycardia,
hypertension, increased oxygen demand, and myocardial
ischemia.
 ...
Respiratory Complications 
 elderly patients - progressive decrease in arterial
oxygen tension, an increase in closing vo...
Neurologic Complications
 confusion or delirium 3rd most common complication seen in
elderly patients
 associated with a...
 develops acutely, but generally has a fluctuating course
over several days
 major risk factors for postoperative deliri...
 Aging alters pharmacokinetics and pharmacodynamics of
most medications, including anesthetics and analgesics.
 may have...
Postoperative management
Analgesia
Epidural analgesia
 excellent, particularly in reducing quadriceps muscle spasm
follow...
NSAIDs used with caution, especially in elderly, owing to
increased risk of renal impairment.
Midazolam infusions or baclo...
Shoulder replacement
Monitoring and intravenous access
 Std full patient monitoring is required
 Large-bore IV access is...
Patient position
 placed in sitting position,
with bolster behind the
shoulder blades to improve
surgical access
 Care s...
Intraoperative problems
 Elderly patients often have poor CVS compensatory
mechanisms while under GA.
 At the start of t...
Revision arthroplasty
 As number of active elderly people increases, more patients
are returning for revision of earlier ...
Monitoring and intravenous access
 Invasive blood pressure and CVP should be considered
 urinary catheter for hourly uri...
Blood loss
 Pre-donation of one unit of blood, using acute
normovolaemic haemodilution, useful if pt has an
adequate star...
Postoperative management
 high dependency unit
 Oxygen should be prescribed for at least 72 hours
 Analgesia should be ...
THANK YOU
Anaesthesia for joint replacement surgeries
Anaesthesia for joint replacement surgeries
Anaesthesia for joint replacement surgeries
Anaesthesia for joint replacement surgeries
Anaesthesia for joint replacement surgeries
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Anaesthesia for joint replacement surgeries

  1. 1. ANAESTHETIC MANAGEMENT OF JOINT REPLACEMENT SURGERIES DR. ARATI MOHAN BADGANDI
  2. 2. INTRODUCTION  Joint replacement – common, effective procedure for relief of disability due to severe joint pain and loss of function.  most common joints replaced are the hip, knee and shoulder.  Most patients for jt replacement have generalized degenerative joint disease (eg.OA).  Other conditions necessitating joint replacement surgery include: › rheumatoid arthritis › osteoporosis and fracture › metastatic lesions and pathological fractures › avascular necrosis of the femoral head.  Most patients are elderly, with associated problems such as HTN, IHD, COPD or renal disease.  Younger pts presenting for jt replacement surgery often suffer from rheumatoid arthritis, severe osteoporosis or obesity.  Presentation for revision of previous replacement is increas­ingly common.
  3. 3. Preoperative assessment  Problems in multiple systems are common because most patients are elderly.  There are specific types of pts who are more likely to have orthopedic surgery and are more likely to have perioperative complications. › geriatric pts › rheumatoid arthritis pts › ankylosing spondylitis pts
  4. 4. Geriatric Patients  Postmenopausal, age­associated osteoporosis ­ higher risk of fractures.  Age­associated osteoporosis may be due to increased circulating parathyroid hormone & decreased vitD, growth hormone.  With osteoporosis ­ disproportionate loss of trabecular (structural) bone – thus at risk for stress fractures.  Although all bones are at risk, thoracic and lumbar spine, proximal femur, proximal humerus, wrist are at highest risk.
  5. 5. Osteoarthritis  most common type of arthritis ­ loss of articular cartilage, inflammation.  Clinical manifestations ­ pain, crepitance, reduced mobility, and deformity of involved joints.  Hands – spurring, swelling of the distal IP jts (Heberden's nodes) and PIP jts (Bouchard's nodes).  no systemic manifestations of osteoarthritis ­ should be aware of previous orthopedic surgeries/ jt replacements / jts which are painful / limited mobility.  important for surgical positioning and the choice of an appropriate anesthetic.
  6. 6. Rheumatoid Arthritis  chronic inflammatory form of arthritis, affects about 1% of adults, prevalence 2­3 times higher in women than men.  characterized by persistent joint synovial tissue inflammation leading to bone erosion, destruction of cartilage, and loss of joint integrity.  RA also a systemic disease, affecting multiple organ systems.  often progresses through multiple exacerbations & remissions.  commonly present with pain and stiffness in multiple joints.  characterized by morning stiffness often lasting >1 hr after initiating activity.
  7. 7.  usually wrists & MCP jts are involved (distinguishes RA from OA), boggy, tender & warm.  may have prominent epitrochlear, axillary, & cervical LN enlargement.  SC rheumatoid nodules may surround joints, extensor surfaces, and bony prominences.  pts taking NSAIDs should be assessed for GI SEs & renal complications.  Glucocorticoids ­ highly effective at relieving symptoms but used at low doses & sparingly ( due to SEs of osteoporosis, cataracts, cushingoid symptoms, hyperglycemia).  Pts taking glucocorticoids need stress­dose steroids for their operations.
  8. 8.  Airway management can be challenging › TMJ synovitis limits mandibular motion & mouth opening. › Arthritic damage to cricoarytenoid joints ­ diminished movement of VCs, narrowed glottic opening; preop as hoarseness and stridor. › During DLscopy, VCs may appear erythematous /edematous, reduced glottic opening may interfere with passage of ETT. › increased risk of cricoarytenoid dislocation with traumatic intubations. › Arthritis of C­spine (atlantoaxial subluxation ­ Flexion of head ­ displacement of odontoid process into cervical spine and medulla ­ compression of vertebral arteries ­ precipitate quadriparesis, spinal shock, and death). › Preop cervical flexion­extension radiographs required to plan for awake fiberoptic tracheal intubation, C­spine should be protected with collar.
  9. 9. Extra­articular manifestations of › Restrictive pericarditis (dyspnea, RHF, fever, chest pain, pericardial friction rub, pulsus paradoxus). › Pleural disease and intrapulmonary nodules. › diffuse interstitial fibrosis with pneumonitis – PFTs restrictive ventilatory pattern ­ respiratory insufficiency, pulmonary HTN, RHF. › Overlapping CTDs ­ Sjögren's syndrome, Felty's syndrome. Airway Limited TMJ movement Narrow glottic opening Cervical spine Atlantoaxial instability Cardiac Pericarditis Cardiac tamponade Eyes Sjögren's syndrome Gastrointestina l Gastric ulcers secondary to ASA, steroids Pulmonary Diffuse interstitial fibrosis Renal Renal insufficiency secondary to NSAIDs
  10. 10. Ankylosing Spondylitis  chronic inflammatory arthritic disease that results in fusion of the axial skeleton.  ossification of axial ligaments progressing from sacral lumbar region cranially, resulting in a significant loss of spinal mobility  significant challenge to us with regard to airway ­ reduced movement of their C­spines & TMJs.  In most cases, awake fiberoptic endotracheal intubation is required for GA.  increased rigidity of the thoracic spine in most cases also necessitates intraoperative controlled mechanical ventilation.
  11. 11.  Although neuraxial anesthesia is better alternative to GA, ossification of spinal ligaments closes intervertebral spaces, blocking access to epidural space. Extraskeletal manifestations 1. aortic insufficiency 2. cardiac conduction abnormalities 3. Iritis 4. upper lobe fibrobullous disease ,pleural effusions.  Strict attention to positioning to avoid fracture of the fused spine with concomitant spinal cord trauma.
  12. 12. Assessment of co-morbidities Cardiopulmonary reserve  estimated by assessment of exercise tolerance.  may be impossible/ inaccurate (limited exercise). In these circumstances the following may be used:  PFTs, ABG, RA SPO2  resting ECG (silent ischaemia / previous MI)  2DEcho (LV function, WMA and valvular abnormality)  limited relevance ­ information only about function of rested, rather than stressed, cardiopulmonary systems.  Dobutamine stress tests provide information about cardiac function under stress but they are not readily available.
  13. 13. Renal function  may be impaired owing to age, HTN or chronic use of NSAIDs. Musculoskeletal  other joint involvement is common.  range of limb and neck movements should be noted.  Obesity may be a cause or consequence of degenerative joint disease.  Assessment for positioning on table and for regional blockade should be made.
  14. 14. Pts Excluded for Single Operation for Bilateral Total Knee Arthroplasty Age ≥ 75 yr ASA class III Active ischemic heart disease (positive stress test) Poor ventricular function (LVEF < 40%) Oxygen-dependent pulmonary disease Patients considered at increased risk for morbidity and mortality IDDM Renal insufficiency Pulmonary hypertension Steroid-dependent asthma Morbid obesity (BMI > 40) Chronic liver disease Cerebrovascular disease
  15. 15. Preoperative preparation  Preop assessment should be carried out as above.  Optimization of co-morbidities is required.  Cross-matched blood must be available.  DVT prophylaxis is required. If a regional technique is planned, ensure appropriate timing of low-molecular- weight heparin.  Antibiotic prophylaxis (usually cephalosporin or aminoglycoside) is required.  Invasive monitoring is seldom indicated unless there is sig- nificant cardiac disease or large blood loss is anticipated.  Large bore IV access is required (non-dependent arm for laterally positioned patients).
  16. 16. Thromboprophylaxis in Orthopedic Surgery  1 of leading causes of morbidity after ortho surgery.  THR, TKR, hip and pelvic fracture surgery - highest incidence of VTE, including DVT and PE.  Pts with symptomatic PE have 18-fold higher risk of death than pts with DVT alone.  short-term complications of survivors of acute DVT and PE - prolonged hospitalization, bleeding complications related to DVT and PE treatments, local extension of DVT, and further embolization.  Long-term complications include post-thrombotic syndrome, pulmonary hypertension, and recurrent DVT.
  17. 17.  As venous thrombi consist of fibrin polymers, anticoagulants administered for the prevention and treatment of DVT.  Thrombolytics should be administered only in event of a severe, possibly fatal PE.  LMWH is recommended over unfractionated heparin (IV/SC) for initial therapy of DVT and PE.  LMWHs do not require monitoring of coagulation.  Although DVT prophylaxis may be more efficient when started preoperatively, the risk of surgical bleeding also increases.  LMWH should be continued for at least 10 days in routine orthopedic procedures & in patients not considered high risk.  Extended prophylaxis to 28 to 35 days would be supported in patients with evidence of a DVT or at higher risk for DVT.
  18. 18.  Risk factors for development of PE after surgery 1. advanced age 2. Obesity 3. previous PE and DVT 4. Cancer 5. prolonged bed rest  Warfarin - long-term treatment of DVT, with a target INR of 2.5 maintained for the duration of therapy.  alternative to LMWH is fondaparinux, synthetic pentasaccharide (selective inhibitor of factor Xa), prolonged half-life of 18 hours.  When administered OD, fondaparinux produces predictable anticoagulant response.
  19. 19.  use of periop anticoagulants has significant impact on use of RA, esp. neuraxial anesthesia (risk of an epidural hematoma).  ASRA - updated consensus conference recommendations with regard to the use of anticoagulants and RA.  risk of epidural hematoma is significantly increased with use of LMWH, so following recommendations have been made: 1. An interval of 12 hrs after administration of usual dose of LMWH and placement of a neuraxial block. 2. In patients receiving larger doses of LMWH (enoxaparin 1 mg/kg every 12 hrs), delay should be extended to 24 hours. 3. Epidural catheter removal at least 8-12 hrs after last LMWH administration, or 1 to 2 hrs before the next.
  20. 20. Intraoperative Management THR APPROACHES  anterior / lateral approach.  anterior approach - advantage of exposure without violation of the muscles, but restricts full access to the femur with the risk of lateral femoral cutaneous nerve injury.  lateral posterior approach - excellent exposure to the femur and the acetabulum with minimal muscle damage, but increases the risk of posterior dislocation.  Most surgeons prefer lateral posterior approach, placing the patient in lateral decubitus position, surgical side up, for operation.
  21. 21. POSITIONING  anesthesiologist must be aware that this position may compromise oxygenation, esp in obese and severely arthritic pts, owing to V/Q mismatch.  to prevent excessive pressure on the axillary artery and brachial plexus by the dependent shoulder, an anterior roll or pad must be placed beneath the upper thorax. TECHNIQUE  nerve supply to hip joint includes obturator, inferior gluteal, and superior gluteal nerves - RA best achieved with SAB/ epidural anesthetic.  lumbar paravertebral block may be used for postop analgesia when postop anticoagulation requires removal of epidural catheter.
  22. 22. BLOOD LOSS  can be significant.  Several studies have shown controlled hypotensive epidural anesthesia with MAP of 60 mm Hg can reduce intraop blood loss for primary THRs to approx 200 mL.  Elderly patients able to tolerate this degree of blood pressure reduction without cognitive, cardiac, or renal complications.  hypotensive anesthesia may improve the cement prosthesis to bone fixation by limiting bleeding in the femoral canal.  femoral prosthesis can be fixed to femoral canal through methyl methacrylate cement or bony ingrowth.  Cemented fixation of the femoral prosthesis has been complicated by “bone-cement implantation syndrome,” which may result in intraop hypotension, hypoxia, and cardiac arrest and FES postoperatively
  23. 23. Several mechanisms suggested –  embolization to circulation of bone marrow debris during pressurization of femoral canal  toxic effects of circulating methyl methacrylate monomer  release of cytokines during reaming of femoral canal promoting microthrombus formation and pulmonary vasoconstriction.  hypotension should be treated with epinephrine.  Risk factors for this complication include revision surgery, a long-stem femoral prosthesis, THR for a pathologic fracture, preexisting pulmonary hypertension, and the quantity of cement used.
  24. 24. TKR TECHNIQUE  innervation of the knee includes tibial nerve, common peroneal nerve, posterior branch of obturator nerve, & femoral nerve.  RA as SAB / CSE / combination of femoral & sciatic block can be provided for the surgery.  Single-injection femoral nerve blocks in combination with intravenous and epidural patient-controlled analgesia have been employed to manage postoperative pain and improve functional recovery.  When LMWH has been instituted for the prevention of DVT, patient-controlled epidural anesthesia cannot be continued postoperatively, and instead continuous femoral nerve catheters are used.
  25. 25. TOURNIQUET APPLICATION  routinely inflated over thigh during TKA to reduce intraop blood loss, provide a “bloodless” field for cement fixation of femoral and tibial components.  when deflated, blood loss usually continues for next 24 hours.  Tourniquets are usually inflated to a pressure 100 mm Hg above pt's SBP for 1 to 3 hours.  Nerve injury after extended tourniquet inflation (>120 minutes) has been attributed to combined effects of ischemia and mechanical trauma.  Peroneal nerve palsy, a recognized complication of TKR caused by combination of tourniquet ischemia and surgical traction.  When prolonged tourniquet inflations are required, deflating the tourniquet for 30 minutes of reperfusion may reduce neural ischemia.
  26. 26.  cuff should be applied over limited padding.  Appropriate selection of tourniquet cuff size and inflation pressure important to reduce risk of NM injury.  cuff should be large enough to comfortably circle the limb to ensure circumferentially uniform pressure.  point of overlap should be placed 180 degrees from the neurovascular bundle because there is some area of decreased compression at the overlap point.  width of the inflated cuff should be >half the limb diameter.  Before tourniquet inflation, the limb should be elevated for approximately 1 minute and tightly wrapped with an elastic bandage distally to proximally.
  27. 27.  duration of safe tourniquet inflation is unknown.  Recommendations range from 30 min - 4 hours.  5 min of intermittent perfusion between 1- and 2-hour inflations, followed by repeated exsanguination through elevation and compression, may allow more extended use.  Prolonged inflation / simultaneous release of 2 tourniquets - significant acidosis, particularly in patients with an underlying acidosis due to other causes eg.DM.  Even with RA, some pts complain of dull, aching pain or become restless.  During surgery, however, opioids and hypnotics are usually effective.  postulated that tourniquet pain is caused by the unblocking of unmyelinated C fibers during recession of a neuraxial block.
  28. 28.  addition of narcotics to spinal or epidural anesthesia may reduce tourniquet pain.  After tourniquet release, MAP falls significantly, partly owing to release of metabolites from ischemic limb into circulation & decrease in PVR.  advantages of SBTKR include exposure to risks of one anesthetic, one postoperative course of pain, reduced rehabilitation and hospitalization, and an earlier return to baseline function.  SBTKA associated, however, with a higher incidence of serious perioperative complications, including myocardial infarction, fat embolization, and thromboembolic events.
  29. 29. Anaesthetic technique General anaesthesia:  if general anaesthesia is indicated, bleeding may be reduced by modest hypotension in carefully selected patients, using volatile agents.  For hip arthroplasty, analgesia may be supplemented by the use of a 3-in-1 (femoral/obturator/lateral cutaneous of thigh) block.  Some anaesthetists favour a lumbar plexus block because this also blocks the sciatic nerve, which has a component supplying the hip.  For knee replacement, a 3-in-1 block combined with a sciatic nerve block can be effective.
  30. 30. Regional anaesthesia is technique of choice because it:  reduce incidence of major periop complications with certain surgical procedures, including DVT, PE, blood loss, respiratory complications.  superior pain relief.  Peripheral nerve blocks employing long-acting anesthetics or catheters may provide excellent intraop anesthesia and superior postop analgesia.  preemptive analgesia.  manipulation of airway, & conscious patients can aid safest & most comfortable positioning for surgery.  suggested that epidural anesthesia reduces venous pressure, & this is significant factor in determining surgical bleeding, decreased need for bank blood and associated transfusion risks.
  31. 31.  Sedation often desirable due to duration of operation, intraop noise.  Oxygen should be administered throughout the operative period.  As sedation deepens, airway obstruction or snoring may occur (not a problem in the lateral position, but some supine patients may require a nasopharyngeal airway).
  32. 32. Intraoperative problems Patient position:  in the lateral position, there is a risk of excessive lateral neck flexion and pressure on the dependent limbs. Hypothermia:  orthopaedic theatres colder than other theatres, with a higher velocity airflow leading to more rapid patient cooling.  Hypothermia causes poor wound healing, infection, coagulopathy and CVS dysfunction.  Fluid warmers, blankets and patient hats should be used routinely.
  33. 33. Blood loss:  average blood loss in THR ranges from 300-1500 ml and may double in the first 24 hours postop.  During TKR with an intraoperative tourniquet, most blood loss occurs in the recovery area.  Careful fluid balance is essential because compensation for hypovolaemia is poor in the elderly. Cement reactions:  At the time of cementing, a drop in blood pressure and oxygen saturation is often seen.  originally thought to be caused by a directly toxic effect of the methyl methacrylate monomer component of the cement, but now known to be caused by a shower of microemboli of blood, fat or platelets forced into circulation by high intramedullary pressure during cement packing and prosthesis insertion.
  34. 34.  Subsequent embolisation to the lungs produces a raised pulmonary vascular resistance and reduction in left ventricular return, resulting in hypotension.  microemboli are toxic to the lung parenchyma, causing haemorrhage, alveolar collapse and hypoxia.  may be severe enough to cause cardiovascular collapse, cardiac arrest and death.  Reactions are more common and more severe in bilateral joint replacements  therefore vital to ensure that the patient is not hypovolaemic before cementing.
  35. 35. Fat Embolism Syndrome  well-known complication of instrumentation of medullary canal.  physiologic response to fat within systemic circulation.  clinical manifestations of FES include respiratory, neurologic, hematologic, and cutaneous signs and symptoms.  presentation of FES can be gradual, developing over 12 to 72 hours, or fulminant leading to ARDS and cardiac arrest.  Gurd and Wilson in 1974 suggested major and minor criteria to be used for the diagnosis of FES.  presence of any 1 major + 4 minor criteria and evidence of fat macroglobulinemia was required for diagnosis of FES.  More recent investigations have indicated that quantity of fat in circulation does not correlate with the severity of FES or development of ARDS
  36. 36. Gurd's Diagnosis of Fat Embolism Syndrome Major Features (at least one)     Respiratory insufficiency    Cerebral involvement    Petechial rash Minor Features (at least 4)     Pyrexia    Tachycardia    Retinal changes    Jaundice    Renal changes Laboratory Features     Fat microglobulinemia (required)    Anemia    Thrombocytopenia    High erythrocyte sedimentation rate
  37. 37. Schonfeld Fat Embolism Syndrome Index Sign Score  Petechial rash 5  Diffuse alveolar infiltrates 4  Hypoxemia Pao2<70 mm Hg,  Fio2 100%3Confusion 1  Fever >38°C (>100.4°F) 1  Heart rate >120 beats/min 1  Respiratory rate >30 1 Score >5 required for diagnosis of fat embolism syndrome
  38. 38.  petechial rash is pathognomonic, usually present on conjunctiva, oral mucosa, and skin folds of the neck and axillae.  mild hypoxemia and radiologic evidence of bilateral alveolar infiltrates, <10% progress to ARDS.  Neurologic manifestations – drowsiness, confusion, obtundation and coma.  treatment of FES is supportive with early resuscitation and stabilization to minimize the stress response to hypoxemia, hypotension, and diminished end-organ perfusion.
  39. 39. Deep Venous Thrombosis and Pulmonary Embolus  VTE major cause of death after surgery or trauma to the lower extremities.  incidence of fatal PE highest in THR for hip fracture.  Effective thromboprophylaxis requires knowledge of clinical risk factors in individual patients, such as advanced age, prolonged immobility or bed rest, prior history of thromboembolism, cancer, preexisting hypercoagulable state, and major surgery.
  40. 40. Antithrombotic Prophylaxis  LMWH started 12 hr before surgery / 12-24 hr after sx, or 4-6 hr after sx at half usual dose & then increasing to usual high-risk dose following day  Fondaparinux (2.5 mg started 6-8 hr after surgery)  Adjusted-dose warfarin started preop or the evening after surgery (INR target, 2.5; INR range, 2.0 to 3.0)  Intermittent pneumatic compression is an alternative option to anticoagulant prophylaxis in patients undergoing total knee (but not hip) replacement
  41. 41. Neueraxial Anesthesia and Analgesia in the Orthopaedic Patient Receiving Antithrombotic Therapy LMWH  placement should occur 10-12 hr after a dose.  Indwelling neuraxial catheters are allowed with once, not twice daily) dosing of LMWH.  optimal to place/remove indwelling catheters in morning and administer LMWH in evening to allow normalization of hemostasis to occur prior to catheter manipulation WARFARIN  Adequate levels of vit K-dependent factors should be present during catheter placement and removal.  Pts chronically on warfarin should have normal INR prior to performance of regional technique.  Monitor PT INR daily. Remove catheter when INR <1.5.
  42. 42. FONDAPARINUX  Neuraxial techniques not advised in pts who are anticipated to receive fondarinux periop. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS  No significant risk of RA-related bleeding is associated with aspirin-type drugs.  pts receiving warfarin or LMWH, combined anticoagulant and antiplatelet effects may increase risk of periop bleeding.  other medications affecting platelet function such as thienopyridine derivatives and glycoprotein IIb/IIIa platelet receptor inhibitors should be avoided.
  43. 43. Postoperative Complications Cardiac Complications  ACC/AHA guidelines recommend preop cardiac testing in pts at increased risk on basis of clinical risk profile, functional capacity, and type of surgery.  orthopedic surgery - intermediate-risk  Older pts have an increased risk of periop myocardial morbidity and mortality after orthopedic surgery possible reasons for this increased risk are as follows:  multiple medical comorbid conditions  limited functional capacity  some ortho procedures initiate a systemic inflammatory response syndrome,  significant blood loss and fluid shifts  postop pain is a major management problem after orthopedic surgery
  44. 44.  All of these factors - stress response - tachycardia, hypertension, increased oxygen demand, and myocardial ischemia.  In pts in whom percutaneous coronary intervention involved placement of stents - added risks of restenosis and thrombosis if antiplatelet therapy discontinued before surgery - increased periop bleeding if not discontinued.  In elderly pts, β-blockers should be continued periop with a target heart rate less than 80 beats/min.  decision to initiate postop physical therapy and rehabilitation, depends on whether there has been a diagnosis of a postoperative myocardial infarction.
  45. 45. Respiratory Complications   elderly patients - progressive decrease in arterial oxygen tension, an increase in closing volumes, decrease of approx 10% in FEV1 with each decade of life.  Due to alterations in chest wall mechanics, exacerbated in arthritis.  hypoxia reflects respiratory changes caused by age or embolization of bone marrow debris to the lungs in these patients.
  46. 46. Neurologic Complications  confusion or delirium 3rd most common complication seen in elderly patients  associated with an increased length of hospital stay, poor functional recovery, progression to dementia, and increased mortality.  Postop delirium manifests as › attention and awareness deficits › including acute confusion › reduced ability to focus › change in cognition › irritability › anxiety › paranoia › hallucinations.
  47. 47.  develops acutely, but generally has a fluctuating course over several days  major risk factors for postoperative delirium › advanced age › alcohol use › preoperative dementia or cognitive impairment › psychotropic medications › multiple medical comorbid conditions. › Perioperative events (hypoxemia, hypotension, hypervolemia, abnormal electrolytes, infection, sleep deprivation, pain, and administration of BZDs and anticholinergic medications).
  48. 48.  Aging alters pharmacokinetics and pharmacodynamics of most medications, including anesthetics and analgesics.  may have longer and more profound CNS effects on elderly patients.  Strategies used to reduce incidence of postoperative delirium – › include identifying risk factors › vulnerable and affected patients › preserving orientation › early mobilization › adequate pain control › maintenance of normal sleep cycles › avoidance of psychotropic medications
  49. 49. Postoperative management Analgesia Epidural analgesia  excellent, particularly in reducing quadriceps muscle spasm following TKRs.  increased risk of urinary retention  catheterisation may cause a bacteraemia, increasing the risk of prosthesis infection. Patient-controlled analgesia is the choice in many institu-tions. Intramuscular opiates may also be considered. Regular paracetamol, 1 g/6 hours, should be given orally or rectally.
  50. 50. NSAIDs used with caution, especially in elderly, owing to increased risk of renal impairment. Midazolam infusions or baclofen are sometimes required to ease quadriceps muscle spasm. Fluid balance: stringent fluid balance monitoring is mandatory because blood loss may double in the first 24 hours. Nausea may reduce the patient’s oral intake. Oxygen: perioperative ischaemia is common and generally silent. Oxygen should be given for the first 72 hours postoperatively.
  51. 51. Shoulder replacement Monitoring and intravenous access  Std full patient monitoring is required  Large-bore IV access is made on the non-operative side  NIBP monitoring is instituted either on the non-operative side with a non-return valve on IV line, or on the lower leg. Anaesthetic technique  GA using an armoured tracheal tube and positive-pressure ventilation.  Access to the patient’s head intraoperatively is extremely restricted.  interscalene approach to brachial plexus blockade provides excellent intraop & postop analgesia, improves operative conditions, decreased blood loss, good muscle relaxation.  commonly gives a unilateral phrenic nerve palsy, seldom causes alveolar hypoventilation, even in spontaneously ventilating patients.
  52. 52. Patient position  placed in sitting position, with bolster behind the shoulder blades to improve surgical access  Care should be taken to ensure that there is no excess strain on the lumbar spine  torso should be securely strapped  head ring  head securely fastened as considerable pull and movement at shoulder.  Access to airway difficult, tracheal tube must therefore be securely taped in place.  eyes should be taped and well padded.
  53. 53. Intraoperative problems  Elderly patients often have poor CVS compensatory mechanisms while under GA.  At the start of the operation, while positioning patient, drop in BP may accompany change from supine to sitting  vasopressors may be required.  at risk of air embolism from open veins at the operative site. Postoperative management  extremely painful and, if pos-sible, interscalene block should be used  supplemented with patient-controlled opiate analgesia.  Regular paracetamol and NSAIDs (in those in whom they are not contraindicated) should also be prescribed.
  54. 54. Revision arthroplasty  As number of active elderly people increases, more patients are returning for revision of earlier replacements.  As well as problems of TKR/THR, revision arthroplasties have added complications associated with prolonged surgery and high blood loss. Preoperative preparation  anticipated blood loss - depends on the type of previous prosthesis and the number of components being revised.  Pre-donation of autologous blood with acute nor- movolaemic haemodilution  Platelets (often not immediately available) and clotting factors may be required.
  55. 55. Monitoring and intravenous access  Invasive blood pressure and CVP should be considered  urinary catheter for hourly urine output measurements. Anaesthetic technique  GA with CSE for pain, or CSE alone  Spinal anaesthesia is generally unsuitable for length of the operation outlasts its effects. Intraoperative problems Temperature:  difficult to prevent perioperative hypo-thermia  long hrs, considerable volumes of intravenous fluid are transfused.  Fluid warmers, hot air blowers, humidification systems and patient hats
  56. 56. Blood loss  Pre-donation of one unit of blood, using acute normovolaemic haemodilution, useful if pt has an adequate starting haemo-globin level.  Platelets and fresh frozen plasma are often required.  Transfusion of pre-donated blood should wait until surgical haemostasis is obtained.  Fluid balance should be guided by surgical blood loss, central venous pressure trends (where available), pulse, blood pressure and urine output, with the aim of maintaining normovolaemia.  haemoglobin con-centration should be assessed from blood gases.
  57. 57. Postoperative management  high dependency unit  Oxygen should be prescribed for at least 72 hours  Analgesia should be pro-vided by epidural infusion with regular enteral paracetamol.  Close control of fluid balance is aided by the use of cen-tral venous pressure monitoring and hourly urine output measurement  Coagulopathies should be treated, but the threshold to transfuse red cells depends, in part, on the pres-ence of co-morbid medical conditions, especially ischaemic heart disease.
  58. 58. THANK YOU
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Anaesthetic management for joint replacement surgeries

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