Anesthesia for Orthopedic surgery อรุณชัย นรเศรษฐกมล.

Anesthesia for Anesthesia for Orthopedic surgeryOrthopedic surgery

อรุ�ณชั�ย นรุเศรุษฐกมลอรุ�ณชั�ย นรุเศรุษฐกมล

ContentContent

General considerationGeneral consideration Age-specific orthopedic conditionsAge-specific orthopedic conditions Medical comorbiditiesMedical comorbidities Coexisting medicationCoexisting medication

Specific considerationSpecific consideration PositioningPositioning Bone cementBone cement Pneumatic tourniquetPneumatic tourniquet Fat embolismFat embolism Deep vein thrombosis & Deep vein thrombosis &

ThromboembolismThromboembolism

Age-specific orthopedic Age-specific orthopedic conditioncondition

Young adultYoung adult ACL reconstruction, Rotator cuffACL reconstruction, Rotator cuff

ElderlyElderly Hip, Knee arthroplastyHip, Knee arthroplasty Hip FractureHip Fracture

Children Children Congenital orthopedic surgeryCongenital orthopedic surgery

Medical comorbiditiesMedical comorbidities

Elderly patientsElderly patients Multiple organ dysfunctionMultiple organ dysfunction

Rheumatoid arthritisRheumatoid arthritis OsteoarthritisOsteoarthritis Ankylosing spondylitisAnkylosing spondylitis

Rheumatoid arthritis Rheumatoid arthritis problem should be awareproblem should be aware

Cervical spine instabilityCervical spine instability IV accessIV access Systemic involvementSystemic involvement Airway managementAirway management Spinal or epidural may be Spinal or epidural may be

difficultdifficult PositioningPositioning

Osteoarthritis

Joint usually involved in Osteoarthritis

Osteoarthritis ( OA)Osteoarthritis ( OA)problem should be awareproblem should be aware

Reduced joint movementReduced joint movement Airway managementAirway management IV accessIV access Spinal or epidural may be Spinal or epidural may be

difficultdifficult PositioningPositioning Concurrent analgesic therapyConcurrent analgesic therapy

Ankylosing spondylitis (AS)Ankylosing spondylitis (AS)problem should be awareproblem should be aware

Fix flexion deformityFix flexion deformity Regional anesthesia may be Regional anesthesia may be

difficultdifficult Abnormal spread of local Abnormal spread of local

anestheticsanesthetics

Coexisting medicationCoexisting medication

Antihypertensive drugsAntihypertensive drugs SteroidsSteroids AspirinAspirin NSAIDsNSAIDs Opioid analgesicsOpioid analgesics Immunosuppressive drugsImmunosuppressive drugs

Specific considerationSpecific consideration

PositioningPositioning

Supine Supine LateralLateral ProneProne Beach chairBeach chair Fracture tableFracture table

Why is positioning important?Why is positioning important?

Enable IV and catheter to remain Enable IV and catheter to remain patentpatent

Enable monitors to function properlyEnable monitors to function properly Facilitates the surgeon’s approachFacilitates the surgeon’s approach Patient safetyPatient safety

Supine Supine

Patient on backPatient on back Arms on arm boardsArms on arm boards

Arm < 90 degreesArm < 90 degrees Arm is supinated ( palm up)Arm is supinated ( palm up) Place padding under elbow if ablePlace padding under elbow if able

Arm tuckedArm tucked Check fingersCheck fingers Check IV lines and SaO2 probeCheck IV lines and SaO2 probe

LateralLateral

Body alignmentBody alignment Keep neck in neutral positionKeep neck in neutral position Always place axillary rollAlways place axillary roll Place padding between kneesPlace padding between knees Place padding below lateral Place padding below lateral

aspect of dependent legaspect of dependent leg

LateralLateral

Position arms to parallel to one Position arms to parallel to one anotheranother Place padding between arms or Place padding between arms or

place non-dependent arm on place non-dependent arm on padded surfacepadded surface

ProneProne

Face downFace down Head placementHead placement

Head straight forwardHead straight forward ET tube placement and patencyET tube placement and patency Check bilateral eyes/ears for pressure pointsCheck bilateral eyes/ears for pressure points

Head turnedHead turned Check dependent eye/ear, ETT placementCheck dependent eye/ear, ETT placement Be aware of potential vascular occlusionBe aware of potential vascular occlusion

ProneProne

Arm placementArm placement Tucked – similar to supineTucked – similar to supine AbductedAbducted

Check neck rotation and arm extension Check neck rotation and arm extension to avoid brachial plexus injuryto avoid brachial plexus injury

Elbow are paddedElbow are padded

Chest rollsChest rolls Iliac supportIliac support

Padding in placed under iliac crestsPadding in placed under iliac crests

Injury occuring from prolonged Injury occuring from prolonged positioningpositioning

Eye compression in prone Eye compression in prone positionposition

Skin breakdown due to Skin breakdown due to prolonged positioningprolonged positioning

Bone cement Bone cement Polymethylmethacrylate: Polymethylmethacrylate: MMAMMA

Bone cement implantation Bone cement implantation syndrome ( BCIS)syndrome ( BCIS)

Release of vasoactive and Release of vasoactive and myocardial depressant substancesmyocardial depressant substances

Intravascular thrombin generation in Intravascular thrombin generation in the lungsthe lungs

Direct vasoactive effects of Direct vasoactive effects of absorbed MMAabsorbed MMA

Acute pulmonary microembolizationAcute pulmonary microembolization

Clinical presentationClinical presentation

Fever Fever HypoxiaHypoxia HypotensionHypotension TachycardiaTachycardia DysrhythmiaDysrhythmia Mental status changeMental status change DyspneaDyspnea End tidal CO2 decreaseEnd tidal CO2 decrease Right ventricular failure and cardiac Right ventricular failure and cardiac

arrestarrest

ManagementManagement

Supportive careSupportive care Monitoring vital signsMonitoring vital signs O2 supplementO2 supplement IV fluidIV fluid VasopressorVasopressor

Pneumatic tourniquetPneumatic tourniquet

No more than 2 hoursNo more than 2 hours 100 mmHg above systolic blood 100 mmHg above systolic blood

pressurepressure 250 mmHg for arm250 mmHg for arm 350 mmHg for leg350 mmHg for leg

Pneumatic tourniquetPneumatic tourniquet

AdvantageAdvantage Eliminate intraoperative bleedingEliminate intraoperative bleeding

DisadvantagesDisadvantages Neurologic effectNeurologic effect Muscle changeMuscle change Systemic effects of the tourniquet Systemic effects of the tourniquet

inflationinflation Syeyemic effects of the tourniquet Syeyemic effects of the tourniquet

releaserelease

Neurologic effectsNeurologic effects

Tourniquet pain and Tourniquet pain and hypertension If > 45-60 minshypertension If > 45-60 mins

Neurapraxia if > 2 hoursNeurapraxia if > 2 hours Nerve injury at the skin level the Nerve injury at the skin level the

edge of the tourniquetedge of the tourniquet

Muscle changesMuscle changes

Cellular hypoxiaCellular hypoxia Cellular acidosisCellular acidosis Endothelial capillary leakEndothelial capillary leak Limb becomes colderLimb becomes colder

Systemic effect of tourniquet Systemic effect of tourniquet inflationinflation

Arterial pressure elevatedArterial pressure elevated

Systemic effect of tourniquet Systemic effect of tourniquet releaserelease

Transient fall in core temperatureTransient fall in core temperature Transient metabolic acidosisTransient metabolic acidosis Release of acid metabolites into Release of acid metabolites into

central circulationcentral circulation Transient fall in arterial pressureTransient fall in arterial pressure Transient increase in EtCO2Transient increase in EtCO2

PreventionPrevention

Select patients Select patients Wide, low-pressure cuffWide, low-pressure cuff Apply the lowest pressure to prevent Apply the lowest pressure to prevent

bleedingbleeding Limit time to 2 hoursLimit time to 2 hours Set maximum pressureSet maximum pressure

Arm 50-75 mmHg above systolicArm 50-75 mmHg above systolic Leg 75-100 mmHg above systolicLeg 75-100 mmHg above systolic

Adequate padding underneathAdequate padding underneath

Fat embolismFat embolism

The mechanical theoryThe mechanical theory The biochemical theoryThe biochemical theory

Clinical findingClinical finding

CardiovascularCardiovascular Persistent tachycardia, hypotensionPersistent tachycardia, hypotension

RespiratoryRespiratory Dyspnea hypoxia hemoptysisDyspnea hypoxia hemoptysis

CerebralCerebral Delirium stupor seizure comaDelirium stupor seizure coma

OphthalmicOphthalmic Retinal hemorrhageRetinal hemorrhage

CutaneousCutaneous petechiaepetechiae

OtherOther Jaundice feverJaundice fever

TreatmentTreatment

ProphylacticProphylactic Early stabilization of the fractureEarly stabilization of the fracture

SupportiveSupportive Respiratory careRespiratory care

Maximize O2, ventilationMaximize O2, ventilation Invasive monitorInvasive monitor

Volume statusVolume status Inotrope Inotrope High dose corticosteroidHigh dose corticosteroid

Deep vein thrombosis & Deep vein thrombosis & ThromboembolismThromboembolismlower extremities, pelvislower extremities, pelvis

Major pathophysiological Major pathophysiological mechanismmechanism Venous stasisVenous stasis Hypercoagulable stateHypercoagulable state Endothelial damageEndothelial damage

Risk FactorRisk Factor

ObesityObesity Age > 60 yearsAge > 60 years Procedure > 30 minsProcedure > 30 mins Use of tourniquetUse of tourniquet Lower extremities fractureLower extremities fracture Immobilization > 4 daysImmobilization > 4 days

PreventionPrevention

Prophylactic anticoagulantProphylactic anticoagulant Low dose heparinLow dose heparin WarfarinWarfarin LMWHLMWH

Intermittent pneumatic Intermittent pneumatic compressioncompression

Neuraxial anesthesia reduce Neuraxial anesthesia reduce thromboembolic complicationthromboembolic complication

Major orthopedic procedureMajor orthopedic procedure

Total hip replacementTotal hip replacement Fracture of the hipFracture of the hip Total knee replacementTotal knee replacement Spinal surgerySpinal surgery

Hip surgeryHip surgery

PatientPatient Limit ability to exerciseLimit ability to exercise Cardiovascular function can be Cardiovascular function can be

difficult to assessdifficult to assess Elderly with systemic disease, Elderly with systemic disease,

OA,RAOA,RA Blood lossBlood loss

Use of hypotensive technique or Use of hypotensive technique or reginal anesthesia reduces blood reginal anesthesia reduces blood lossloss

PositioningPositioning Mostly lateral decubitus positionMostly lateral decubitus position Ventilation perfusion mismatchVentilation perfusion mismatch Neurovascular problemNeurovascular problem

Potentially life-threatening Potentially life-threatening complicationcomplication

Bone cement implantation Bone cement implantation syndromesyndrome

Intra and postoperative Intra and postoperative hemorrhagehemorrhage

Venous thromboembolismVenous thromboembolism

Important factor of mortalityImportant factor of mortality

Very old ageVery old age Female>maleFemale>male Hip fractureHip fracture ObesityObesity SmokingSmoking MalnutritionMalnutrition Baseline cardiopulmonary functionBaseline cardiopulmonary function

Anesthetic concernsAnesthetic concerns

Invasive monitoringInvasive monitoring Blood lossBlood loss PositioningPositioning Cement fixationCement fixation Deliberate hypotensionDeliberate hypotension

GA or RAGA or RA

GAGA Decrease lung Decrease lung

functionfunction Depress coughDepress cough Increase Increase

secretionsecretion Depress cardiac Depress cardiac

functionfunction

RARA Reduce lung Reduce lung

complicationcomplication Reduce Reduce

thromboembolithromboemboli Reduce deliriumReduce delirium Reduce blood Reduce blood

lossloss

Revision hip arthroplastyRevision hip arthroplasty

Blood lossBlood loss Longer durationLonger duration Deliberate hypotension or Deliberate hypotension or

regional should be usedregional should be used

Total knee arthroplastyTotal knee arthroplasty

Preoperative considerationPreoperative consideration Same as THRSame as THR Severe rheumatoid arthritisSevere rheumatoid arthritis OsteoarthritisOsteoarthritis ObesityObesity comorbiditycomorbidity

Anesthetic managementAnesthetic management

ThromboembolismThromboembolism Fat embolismFat embolism CementCement Postoperative blood lossPostoperative blood loss Postoperative pain; more than Postoperative pain; more than

THRTHR