Anesthesia for orthopaedic replacement surgeries Prof.Dr.K.BALAKRISHNAN,Chennai.

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.