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Anesthesia for Total Knee replacement 4-3-2017
This document discusses anesthesia considerations for total knee replacement (TKR) surgery. It covers preoperative evaluation of cardiopulmonary and musculoskeletal systems, anesthesia techniques including spinal, epidural, peripheral nerve blocks and general anesthesia, intraoperative monitoring and tourniquet use, postoperative care including pain management, and complications associated with TKR such as blood loss, infection and venous thromboembolism. Regional anesthesia techniques are preferred due to advantages like less blood loss, better pain control and early mobilization, though patient factors and surgical needs determine the best option.
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Anesthesia for Total Knee replacement 4-3-2017
- 1. ANESTHESIA FOR TKR AftabHussain
- 2. • What arethe conditions requiring knee replacement ?
- 3. • Most ofthe patients have degenerative joint disease, commonly osteoarthritis (OA). • injury to knee joint, • knee deformity, • rheumatoid arthritis • Gout • Hemophilia
- 4. Joint replacement isperformed to relieve - • pain and • morbidity.
- 5. • What arethe challenges associated with TKR patients ?
- 6. The challenges…. • Decreasedorgan function and reserve due to aging. • Co-morbid conditions • Pain • Obesity • Consequences of poly-pharmacy
- 7. What are majorconcerns in preoperative period ? • Cardiopulmonary ? • Musculoskeletal ?
- 8. Cardiopulmonary • Cardiopulmonary reservedifficult to assess as exercise tolerence is limited by knee disease. • Resting ECG may show silent ischemia or previous MI. • Dynamic function such as cardiopulmonary exercise or pharmacological stress test difficult to perform.
- 9. Evaluation of thefunctional cardiovascular reserves ? Cardiac Risk Index?
- 10. • Simple steps(e.g., auscultation, ECG, and chest x-ray) can detect acute decompensation. • Echocardiography if feasible at the bedside. • Evaluation of electrolytes and blood count is required. • Metabolic equivalent (MET) ?
- 11. • Metabolic equivalent(MET) • Metabolic equivalent gold standard to evaluate patients physical capacity. • MET >4 associated with decreased risk of perioperative cardiovascular events.
- 12. Revised cardiac riskpredictors • History of Ischemic heart ds • History of CHF • History of Cerebrovascular ds • History of diabetes • Chronic kidney ds • Type of surgery. • Risk of MI or Cardiac arrest 0= 0.4%, 1 = 0.9%, 2= 6.6%, >3= >11%
- 13. • What arethe implication of Musculoskeletal examination in these patients ?
- 14. Musculoskeletal system • Otherjoint involvement is common which have implications for positioning for regional anaesthesia & surgery. • Obesity may be present. • Rheumatoid Arthritis – cervical spine involvement TMJ involvement ?
- 15. TMJ involvement Restricted mouthopening Difficult Intubation Regional Anaesthesia is better option
- 16. H/o Drugs – .If patient is taking warfarin, aspirin, clopidogrel More chances of hematoma formation in regional anaesthesia . Beta blockers – can be continued Anti hypertensive drugs?
- 17. • What isAmerican society of regional anesthesia(ASRA) recommendation??
- 18. NEURAXIAL BLOCKADE ,ANTICOAGULANTS ANDANTIPLATELET AGENTS • Pts taking NSAIDS or receiving Aspirin in low dose(75mg/day) are not viewed as being at increased risk of spinal hematoma • DISCONTINUE---ticlopidine 2 weeks, clopidogrel for 1 week ,abciximab 24 to 48 hrs, eptifibate and tirofiban 4 to 8 hrs before performing central neuraxial block.
- 19. • What arethe investigations required ?
- 20. Investigations - BloodCounts Renal function test ECG Blood Grouping Coagulation Profile Chest X-ray
- 21. The choice ofanaesthesia is determined by: i) surgical factors ii) Patients factors iii) Estimates of risk associated with anaesthesia techniques Choice Of Anaesthesia
- 22. • Name anaesthetictechniques for TKR ?
- 23. TKR – 1.Combined Spinal Epidural 2. Epidural 3. Spinal 4. GA with femoral & sciatic nerve block 5. Femoral & sciatic n. block alone 6. General Anaesthesia
- 24. Anaesthesia SPINAL If nocontraindication Preload with IV fluid before performing spinal. In TKR Avoid excessive preload before performing spinal
- 25. • For asingle shot spinal use 2.5 – 3.0 mls of 0.5% bupivacaine depending on patient size.
- 26. • CONTRAINDICATIONS OF NEURAXIALBLOCKADE??
- 27. ABSOLUTE 1. patients refusal 2.coagulopathy 3. infection at local site 4. severe hypovolemia 5. increased ICT 6. allergy to drugs 7. shock 8. severe AS or MS RELATIVE 1. uncoperative pt 2. preexisting neurological deficits 3. demyelinating lesions 4. severe spinal deformity 5. sepsis
- 28. • Adjuvants addedto prolong effect of spinal anaesthesia ?
- 29. • Opiate maybe added for more prolonged analgesia and to cover longer surgery (up to 3 hours). Opioid Dose Duration of action Fentanyl 25mcg 1-4 hrs Butorphenol 50-100 mcg 2-3 hrs Alpha 2 agonist Clonidine ? 25mcg 2-3 hrs
- 30. • Light sedationusing increments of midazolam 0.5mg or low dose target controlled infusion of propofol may be used. • For long cases – Epidural & combined spinal epidural
- 31. PERIPHERAL NERVE BLOCKS •Peripheral nerve blocks employing long-acting anesthetics or catheters may provide excellent intraoperative anesthesia and superior postoperative analgesia.
- 32. • Peripheral nerveblock for TKR ?
- 33. Peripheral nerve blocksfor TKR • (3 in 1) blocks have become popular and provide good analgesia in the first 12-24 hrs. • They avoid the need for a urinary catheter in most patients and allow mobility in bed. • They need 30 minutes to become effective and do not provide surgical anaesthesia.
- 34. • Femoral 3in 1 block … ?
- 35. • Historically femoralnerve block was thought to block femoral, lateral femoral cutaneous nerve and obturator nerve. • Most of the time obturator nerve is not blocked.
- 36. • What arethe advantages of regional anaesthesia ?
- 37. Regional Anesthesia -Advantages Stress response to surgery Intraoperative blood loss Post-operative hypoxia PONV DVT- early mobilization
- 38. GENERAL ANAESTHESIA • Spontaneousventilation via LMA • Ventilation via endotracheal tube
- 39. • What arethe advantages of general anaesthesia ?
- 40. General Anaesthesia - Advantages •Better for patients who are unable to lie flat. • Safer for patients with fixed cardiac output states such as aortic stenosis. • Patient preference. • Less likely to require urinary catheterisation.
- 41.
- 42. Perioperative… Monitoring – NIBP ECG PULSEOXIMETER CAPNOGRAPH URINE OUTPUT
- 43. • What isthe use of tourniquet in TKR and morbidity associated with it ?
- 44. Tourniquet - Usedin TKR so perioperative blood loss is not a problem until its release. Tourniquet pain occur after about 1 hr causing increased HR & BP (GA) and it can occur even with regional anaesthesia. Tt – deepen anaesthesia opioids
- 45. • Risks associatedwith tourniquet deflation ?
- 46. Tourniquet deflation • Afterdeflation of the tourniquet a short- lived reperfusion event commonly occurs. • Acidic products of metabolism are washed out of the limb causing peripheral vasodilatation and reduced cardiac contractility, both of which result in a drop in blood pressure.
- 47. • End-tidal CO2rises and a fall in oxygen saturation is often seen. • Prevention involves fluid loading before and during tourniquet release. Additional oxygen and vasopressors may be required.
- 48. • Antibiotic prophylaxis.. When ?
- 49. Antibiotic Prophylaxis Infection isone of the most common complication after TKR. So all patients should receive antibiotic prophylaxis. Administered within 1 hr prior to skin incision. If tourniquet is to be used, should be given prior to tourniquet inflation.
- 50. • Post opcare ?
- 51. Immediate postoperative careto support oxygenation, controlling pain, and early mobilisation Post-operative care
- 52. • Oxygen therapyfor 24 hours is advisable in most patients, continued up to 72 hours in those at high risk of myocardial ischaemia.
- 53. • Post operativePain management ?
- 54. • Patient education •Preemptive analgesia ? • Neuraxial analgesia • Peripheral nerve block • Periarticular injection • PCA • Oral analgesics • Multimodal analgesia ?
- 55. • Effective postop analgesia is essential for early physical rehabilitation to maximize postoperative range of motion and prevent joint adhesions. • Patients usually undertake passive exercises in the operated leg within 24 hours and are mobilized at 48 hours.
- 56. • What arethe complications associated with TKR ?
- 57. COMPLICATIONS • Blood loss– • In TKR Blood loss may be brisk after deflation of the tourniquet, and if it exceeds 500 mls the surgeon may clamp the drain for a period.
- 58. Venous Thromboembolism • Morecommon in TKR. • Clinical DVT occurs in 10% of patients without prophylaxis and fatal pulmonary embolism in 0.4% of patients.
- 59. • Strategies toprevent Venous thromboembolism ?
- 60. • Strategies tominimise risk include - .avoiding dehydration, .early mobilisation, .regional anaesthesia, .intermittent leg-compression devices, .graduated compression stockings.
- 61. • Prophylaxis forDVT ?
- 62. Prophylaxis against DVT •Low dose heparin, low molecular weight heparin (LMWH), warfarin, or the selective factor Xa inhibitor, fondaparinux are effective in reducing DVT. • concern about possible bleeding complications • Recommendations allow a 12 hour interval between low molecular weight heparin and epidural/spinal injection. This also applies to removal of an epidural catheter.
- 63. • SBTKR ? •Advantages and disadvantages?
- 64. • SBTKR --Simulataneous B/l, TKR • Advantages and disadvantages?
- 65. • Advantages: One anaestheticexposure Postop pain course Reduced rehabilitation Earlier return of baseline function • Disadvantages Increased perioperative complications More blood transfusions Risk of ICU admissions.
- 66. • Persistent postoperative pain ?
- 67. Persistent postoperative pain •Pain lasting >3 months • Can affect 10-50% of certain surgical patients (44% of TKR)* • Risks?
- 68. • Female sex,depression and presence of pain in more than one body location. • Presence of pre-surgical pain >1year also found to be significant risk factors to become chronic pain.
- 69. Conclusion • Geriatric patientsfor 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.
- 70.
Editor's Notes
- #55 Effective reduction in cemntral and peripheral sensitization and postoperative pain level and result in decreased consumption of analgesics. Multimiodal pain management combined use of drugs or procedures that have different mech of action can be more effective in improveing pain and reducing the consumption of each agent. In particular opioids.