1.
Anesthesia for
Orthopedics surgery
Moderator :
Assoc. Prof Dr. Sujita Manandhar
Assist. Prof Dr. Pawan Kumar Hamal
Presenter : Dr. Krishna Dhakal

2.
Learning objectives
• Describe general considerations and goals related to orthopedic
surgery
• Describe specific consideration associated with orthopedic
surgery ,their anesthetic implications and management
• Describe briefly about special orthopedic condition and their
anesthetic concerns
2/7/2019 2
Department of Anesthesiology and
Critical Care ,NAMS

3.
• General consideration
1. Perioperative Goals
a) Pre op considerations
b) Intraoperative Goals
c) Post operative considerations
2. Age specific orthopedic conditions
3. Medical comorbidities
4. Co existing medications
2/7/2019 3
Department of Anesthesiology and Critical
Care ,NAMS

4.
• Specific considerations
1. Positioning
2. Bone cement Implantation syndrome
3. Pneumatic Tourniquets
4. Fat embolism
5. Deep vein thrombosis and thromboembolism
6. Regional anesthesia and anticoagulation
2/7/2019
Department of Anesthesiology and Critical
Care ,NAMS
4

5.
• Pre op considerations
1. Age
2. Co morbidities
3. Medications
4. Diagnostic studies
2/7/2019
Department of Anesthesiology and Critical
Care ,NAMS
5

6.
Pre op considerations
• 1.Age of the patients
• Elderly
• Medical Conditions(MI,COPD,HTN CVD,DM)
• Anticoagulation therapy
• Renal dysfunctions
• Airway difficulties
• Osteoporesis
• Pediatrics
• Congenital deformities
• Undiagnosed muscular dystrophies
2/7/2019 6
Department of Anesthesiology and Critical
Care ,NAMS

7.
Pre-op considerations
2. Comorbidities
• Trauma- stabilization
• Geriatric populations- HTN,CAD,CVD,COPD, osteoarthritis, RA
• Obesity-HTN,CAD,DM
3. Medications
• Steroids
• Opiods
• Antihypertensives
• NSAIDS
• Immunotherapy-Methotrexate
2/7/2019 7
Department of Anesthesiology and Critical
Care ,NAMS

8.
Pre-op considerations
• Radiologic studies
• C-xray
• Xray –C spine-AP, lateral
• Cardiac studies
• ECG
• Echocardiography
• Labs
• CBC
• Platelets
• Renal functions,electrolytes
• Coagulation studies-
Anticogulation
medications,immunetherapy
2/7/2019 8
Department of Anesthesiology and Critical
Care ,NAMS

9.
Choice of Anesthetic Technique
• Regional anesthesia vs General anesthesia
2/7/2019 9
Department of Anesthesiology and Critical
Care ,NAMS

10.
Choice Of Anesthesia Technique contd..
Many orthopedic surgery because of localized peripheral sites led
themselves to RA techniques
Advantages of RA
• No or minimal airway manipulation
• Improved postoperative analgesia
• Decreased incidence of PONV
• Less respiratory and cardiac depression
• Reduced blood loss
• Decrease risk of DVT/Thromboembolism
2/7/2019
Department of Anesthesiology and Critical
Care ,NAMS
10

11.
Upper Extremity Surgery
RA (+/- GA)
1. IRVA(Intravenous Regional Anesthesia)
• Advantage: simplicity of technique, rapid onset of action, controllable
duration of action and rapid return of function.
• Disadvantage: continuous use of tourniquet, the potential toxic effect
of the drug and lack of postoperative analgesia.
2. Brachial Plexus Block
3. Blockade of peripheral nerves
• Radial Nerve block.
• Median Nerve block.
• Ulnar Nerve block.
• Digital Nerves.
2/7/2019 11
Department of Anesthesiology and Critical
Care ,NAMS

12.
Lower Extremity Surgery
• Can be completely performed under regional anesthesia
2/7/2019 12
Department of Anesthesiology and Critical
Care ,NAMS

13.
Regional anesthesia technique for surgery of the
lower extremity
1. Hip
2. Knee
3. Lower leg
4. Ankle
5. Foot
• Spinal, epidural, lumbar plexus block.
• Spinal,epidural,3 in 1 block, femoral
sciatic block.
• Spinal, epidural, sciatic block, femoral-
sciatic block, sciatic and saphenous
block.
• Spinal, sciatic block
• Spinal, sciatic, ankle block, trans
metatarsal block.
2/7/2019 13
Department of Anesthesiology and Critical
Care ,NAMS

14.
Intraoperative Goals
• Surgical anesthesia
 To provide optimal surgical operating conditions
 Appropriate depth of anesthesia
 Adequate pain control
• Optimize surgical exposure
 Neuromuscular blockade in GA
 Neuraxial anesthesia
 Peripheral nerve block
2/7/2019 14
Department of Anesthesiology and Critical
Care ,NAMS

15.
Intraoperative Goals
• Proper positioning to Prevent stretch/compression nerve
injuries
• Prevent significant blood loss
may be reduced through
• proper positioning
• intraoperative blood salvage,
• induced hypotension,
• intraoperative hemodilution, and
2/7/2019
Department of Anesthesiology and Critical
Care ,NAMS
15

16.
Post operative considerations
• Postoperative pain management
• Peripheral nerve blockade with or without catheter
• Opioids for breakthrough pain/multimodal analgesia
• NSAIDs and adjuvant analgesic medications
• Others
• ICU/Post op care
• Mechanical ventilation: if needed
2/7/2019 16
Department of Anesthesiology and Critical
Care ,NAMS

17.
Specific Considerations
2/7/2019
Department of Anesthesiology and Critical
Care ,NAMS
17

18.
Positioning
• Why positioning important??
1. Patient safety
2. Prevent nerve injuries
3. Enable iv access, ET Tube , catheter to remain patent
4. Enable proper monitor
5. Facilitates surgical approach
2/7/2019
Department of Anesthesiology and Critical
Care ,NAMS
18

19.
Positioning
• Supine
• Lateral
• Prone
• Beach chair
• Fracture table
2/7/2019
Department of Anesthesiology and Critical
Care ,NAMS
19

20.
Positioning contd..
• Supine
• Patient on back
• Arms on arm boards
• Arm < 90 degrees
• Arm is supinated ( palm up)
• Place padding under elbow if
able
• Arm tucked
• Check fingers
• Check IV lines and SpO2
probe
2/7/2019 20
Department of Anesthesiology and Critical
Care ,NAMS

21.
Positioning contd..
 Lateral
 Body alignment
 Keep neck in neutral position
 Always place axillary roll
 Place padding between knees
 Place padding below lateral aspect
of dependent leg
 Position arms to parallel to one
another
 Place padding between arms or
place non-dependent arm on
padded surface
2/7/2019 21
Department of Anesthesiology and Critical
Care ,NAMS

22.
Positioning contd…
• Prone
• Face down
• Head placement
• Head straight forward
• ET tube placement and
patency
• Check bilateral eyes/ears
for pressure points
• Head turned
• Check dependent eye/ear,
ETT placement
• Be aware of potential
vascular occlusion
2/7/2019 22
Department of Anesthesiology and Critical
Care ,NAMS

23.
Positioning contd..
• Prone
 Arm placement
 Tucked – similar to supine
 Abducted
▪ Check neck rotation and arm
extension to avoid brachial
plexus injury
▪ Elbow are padded
 Chest rolls
 Iliac support
 Padding in placed under iliac crests
2/7/2019 23
Department of Anesthesiology and Critical
Care ,NAMS

24.
Positioning contd..
Beach Chair
• Arms- supported to prevent
stretching of the brachial
plexus.
• Elastic stockings and active leg
compression devices - help
maintain venous return.
2/7/2019 24
Department of Anesthesiology and Critical
Care ,NAMS

25.
Positioning contd..
• Fracture chair
• Maintenance of traction on the
fractured extremity, allowing
• manipulation for closed reduction
and fixation, and
• access to the fracture site for
radiography in several planes
• The ipsilateral arm is positioned on
an arm board or sling without
stretching the brachial plexus
• Gentiles protection
2/7/2019 25
Department of Anesthesiology and Critical
Care ,NAMS

26.
Bone Cement Implantation Syndrome
• Bone cement Syndrome
Characterised by hypoxia , hypotension or both and or unexpected
loss of consciousness occurring at the time of cementation,
prosthesis insertion ,reduction of joint or occasionally, limb
tourniquet deflation in a patient undergoing cemented bone
surgery
• Bone cement-
Methyl methacrylate(MMA) an acrylic bone cement used during
arthroplastic procedures.
Donaldson et al 2009
2/7/2019 26
Department of Anesthesiology and Critical
Care ,NAMS

27.
2/7/2019
Department of Anesthesiology and Critical
Care ,NAMS
27

28.
•Clinical presentations
• Fever
• Hypoxia
• Hypotension
• Tachycardia
• Dysrhythmia
• Mental status change
• Dyspnea
• Decreased End tidal CO2
• Right ventricular failure and
cardiac arrest
2/7/2019 28
Department of Anesthesiology and Critical
Care ,NAMS

29.
•Treatment strategies
1. Increasing FiO2 prior to cementing
2. Monitoring & maintaining hydration
3. Creating vent hole in the distal femur
4. High pressure lavage of femoral shaft to remove debris
5. Using cementless prosthesis
2/7/2019 29
Department of Anesthesiology and Critical
Care ,NAMS

30.
2/7/2019 30
Department of Anesthesiology and Critical
Care ,NAMS

31.
Pneumatic tourniquet
• To create bloodless field
• Not > 2 hours
• Prolonged inflation (>2hrs) leads
to
-transient muscle dysfunction
- rhabdomyolysis,
-nerve injuries
• 100 mmHg above systolic blood
pressure
2/7/2019 31
Department of Anesthesiology and Critical
Care ,NAMS

32.
Pneumatic tourniquet
• Advantage
• Eliminate intraoperative
bleeding
• Disadvantages
• Neurologic effect
• Muscle change
• Systemic effects of the
tourniquet inflation
• Systemic effects of the
tourniquet release
2/7/2019 32
Department of Anesthesiology and Critical
Care ,NAMS

33.
Pneumatic tourniquet
•Problems with inflation
• Pain
• Sympathetic stimulation:
Marked HTN, tachycardia, and diaphoresis
• Arterial thromboembolism, pulmonary embolism
• If prolonged >2 hour
Transient muscle dysfunction  rhabdomyolysis, permanent
nerve damage
• Folds or lines under tourniquet may cause bruising or pressure
necrosis of skin
2/7/2019 33
Department of Anesthesiology and Critical
Care ,NAMS

34.
• Problems with deflation
• The good: decreases the tourniquet pain experienced
• Disadvantages
• Increase in blood level of: PaCo2, lactate, potassium: d/t washout of
accumulated waste
• Increase. in MV of spontaneously breathing patients
• Transient metabolic acidosis
• Core temperature decreases
2/7/2019 34
Department of Anesthesiology and Critical
Care ,NAMS

35.
Prevention
• Select patients
• Wide, low-pressure cuff
• Apply the lowest pressure to prevent bleeding
• Limit time to 2 hours
• Set maximum pressure
-Arm 50-75 mmHg above systolic
-Leg 75-100 mmHg above systolic
• Doppler guided tourniquet pressure inflation
• Adequate padding underneath
2/7/2019 35
Department of Anesthesiology and Critical
Care ,NAMS

36.
Fat Embolism Syndrome
• A well known complication of skeletal trauma and surgery
involving femoral medullary canal
• A physiologic response to fat within systemic circulation
• FES <2 - 22% , all long bone fracture
• Mortality rate - 10-20 %
• Presents within 72 hrs. following fracture of long bone,pelvis
with triad of – Dyspnea, confusion, petechiae
2/7/2019 36
Department of Anesthesiology and Critical
Care ,NAMS

37.
2/7/2019
Department of Anesthesiology and Critical
Care ,NAMS
37

38.
Clinical manifestations
• Neurologic: agitation, confusion,
stupor, coma
• Hematologic: thrombocytopenia,
prolonged CT
• Cutaneous: petechiae
(pathognomonic)
• Pulmonary: mild hypoxia, resp.
failure, ARDS (10%)
• CVS: persistent tachycardia,
hypotension
Dyspnea
Confusion Petechiae
2/7/2019 38
Department of Anesthesiology and Critical
Care ,NAMS

39.
Gurd's Diagnosis of FES
• Major Features (at least one)
• Respiratory insufficiency: PaO2 <60
mm Hg, FiO2: 0.4
• Cerebral involvement: altered
mentation
• Petechial rash
• Minor Features (at least four)
• Pyrexia
• Tachycardia
• Retinal changes
• Jaundice
• Renal changes
• Laboratory Features
• Fat microglobulinemia
• Anemia
• Thrombocytopenia
• High ESR
Gurd AR, Wilson RI: The fat embolism syndrome. J Bone Joint Surg Br 56:408-416, 1974
2/7/2019 39
Department of Anesthesiology and Critical
Care ,NAMS

40.
Schonfield index
• A score of >5 required for
the diagnosis of FES
Schonfeld SA, Ploysongsang Y, DiLisio R, et al: Fat embolism prophylaxis with corticosteroids: A prospective
study in high risk patients. Ann Int Med 99:438-443, 1983.
2/7/2019
40

41.
How to diagnose FES under GA
• Decline in end tidal CO2
• Decline in arterial oxygen saturation
• Rise in pulmonary artery pressures
ECG
• Ischemic-appearing ST segment changes
• Right sided heart strain
2/7/2019 41
Department of Anesthesiology and Critical
Care ,NAMS

42.
Treatment
Prophylactic
 Early stabilization of the fracture
Supportive
 Respiratory care
▪ O2 therapy (with CPAP ventilation - ARDS)
 Invasive monitoring
▪ Volume status, Inotrops
▪ Vasodilators for Pulmonary HTN
 High dose corticosteroid
2/7/2019 42
Department of Anesthesiology and Critical
Care ,NAMS

43.
One of the leading causes of morbidity and mortality after
major orthopedic surgeries like THA, TKA, hip and pelvic
fracture surgeries.
• Incidence of DVT : 40-80% without prophylaxis
• Incidence pulmonary embolism is 20%(Fatality-1-3%)
• Major pathophysiological mechanism(Virchow’s Triad)
• Venous stasis
• Hypercoagulable state
• Endothelial damage
DVT And Thromboembolism
2/7/2019 43
Department of Anesthesiology and Critical
Care ,NAMS

44.
DVT/Thromboembolism contd..
Risk Factors
• Obesity
• Age > 60 years
• Previous PE and DVT
• Cancer
• Procedure > 30 mins
• Use of tourniquet
• Lower extremities fracture
• Immobilization > 4 days
• Thrombophilia: mainly
hereditary eg. Factor V Leiden
(most common)
2/7/2019 44
Department of Anesthesiology and Critical
Care ,NAMS

45.
Prevention
• Non-pharmacological
• Intermittent pneumatic compression
• TED stockings
• IVC filters: in patients C/I for anticoagulation
• Pharmacological
• Low dose heparin (UF)
• Warfarin
• LMWH
• Recent alternatives to:
• Fondaparinux
• Dabigatran
2/7/2019 45
Department of Anesthesiology and Critical
Care ,NAMS

46.
•Treatment
• Anticoagulants OR Thrombolytics?
• Venous thrombi  Fibrin thrombi  anticoagulation for Prevention and treatment
• Severe, possibly fatal PE  Thrombolytics
WARFARIN
Blocking of Vit K dependent
coagulation factors
II, VII, IX, and X)
LMWH
inactivating thrombin and activated factor X
(factor Xa) through an antithrombin (AT)-
dependent mechanism
2/7/2019 46
Department of Anesthesiology and Critical
Care ,NAMS

47.
Regional Anesthesia and anticoagulation
• Regional anesthesia and anticoagulation are important
considerations in orthopedic surgeries.
• A plan management for anticoagulant and anesthetic technique
must be taken for the specific patient under anticoagulation
2/7/2019 47
Department of Anesthesiology and Critical
Care ,NAMS

48.
2/7/2019 48
Department of Anesthesiology and Critical
Care ,NAMS

49.
2/7/2019 49
Department of Anesthesiology and Critical
Care ,NAMS

50.
2/7/2019 50
Department of Anesthesiology and Critical
Care ,NAMS

51.
Anesthetic considerations
Rheumatoid arthritis
2/7/2019 51
Department of Anesthesiology and Critical
Care ,NAMS

52.
Osteoarthritis
• Anesthetic concrens
• Reduced joint movement
• Airway management
• IV access
• Spinal or epidural - difficult
• Positioning
• Concurrent analgesic therapy
2/7/2019 52
Department of Anesthesiology and Critical
Care ,NAMS

53.
Ankylosing spondylitis
• Ankylosing spondylitis involves ossification of the axial ligaments
progressing from the sacral lumbar region cranially,
• Significant loss of spinal mobility
• Regional anesthesia may be difficult
• Reduced movement of C-spine and TMJ
• Thoracic spine movement restriction
• Difficulty in positioning
• Others:
• Aortic insufficiency, cardiac conduction defects, and pleural effusions.
2/7/2019 53
Department of Anesthesiology and Critical
Care ,NAMS

54.
Anesthesia for spinal surgery
•Pathological condition requiring spine surgery are
– Spinal cord compression
– Herniation of an intervertebral disk
– Spinal deformities (scoliosis)
– Tumor or infection
– Vascular malformation
– Post traumatic stabilization
2/7/2019 54
Department of Anesthesiology and Critical
Care ,NAMS

55.
Preoperative assessment
•Airway evaluation
•Respiratory evaluation
•Cardiovascular evaluation
•Neurological evaluation
2/7/2019 55
Department of Anesthesiology and Critical
Care ,NAMS

56.
Monitoring
•Standard monitoring:
•NIBP, SPO2, HR, ECG, Capnograph, temperature
•Special monitoring:
•Invasive blood pressure, central venous pressure and urine output
2/7/2019 56
Department of Anesthesiology and Critical
Care ,NAMS

57.
Problems associated with prone position in
Spine Surgery
1. Chest pressure - decreased chest compliance and impaired
respiration.
2. Abdominal pressure -inferior vena cava compression -
retrograde venous flow into the vertebral venous plexus -
resulting in epidural venous engorgement.
3. Peripheral nerve damage - as a result of excessive pressure or
traction.
4. Eyes, ears, nose, breast, and genitalia must be protected from
excessive pressure
2/7/2019 57
Department of Anesthesiology and Critical
Care ,NAMS

58.
2/7/2019 58
Department of Anesthesiology and Critical
Care ,NAMS

59.
Take home message
• Older age is a significant risk factor for poor outcome after
orthopedic surgery. They often have multiple comorbid
conditions that must be considered in the perioperative plan
• Proper positioning for orthopaedic procedures is paramount to
providing optimal surgical conditions, as well as avoiding
potential stretch and compression injuries.
• Fat embolism syndrome and bone cement implantation
syndrome - result in life threatening emergency thus
anticipation and management should be prompt
• Patients undergoing major orthopaedic are at high risk for
thromboembolic complications. Use of current pharmacologic
and mechanical methods of thromboprophylaxis is required
2/7/2019 59
Department of Anesthesiology and Critical
Care ,NAMS

60.
Take home message
• Pneumatic tourniquets are often used to create a bloodless field but
also are associated with potential problems; hemodynamic changes,
pain, metabolic alterations, arterial thromboembolus, and even
pulmonary embolism
• Regional anaesthesia reduces perioperative complications compared
with GA, and may provide superior analgesia
• Regional anaesthesia and anticoagulation are important
considerations in orthopaedic surgeries. A plan management for
anticoagulant and anesthetic technique must be taken for the
specific patient under anticoagulation
2/7/2019 60
Department of Anesthesiology and Critical
Care ,NAMS

61.
References
• Mikhail & Morgan’s Clinical Anesthesiology, 5th edition
• Barash, Paul G Cullen Clinical Anesthesia, 8th edition
• Ronald D. Miller Miller's Anesthesia , 7th edition
• American Society of Regional Anesthesia and Pain Medicine, Evidence-
Based Guidelines on regional anesthesia and anticoagulation,
3rd Edition
• Internet: www.asra.com/advisory-guidelines/article/4/interventional-
spine-and-pain-procedures-in-patients-on-antiplatelet-and-anticoa
2/7/2019 61
Department of Anesthesiology and Critical
Care ,NAMS

62.
Thank You
2/7/2019 62
Department of Anesthesiology and Critical
Care ,NAMS