11Challenges have been converted into good outcomes… Better understanding on pathophysiology of agingBetter pharmacotherapySafer anaesthetic techniquesImprovements in monitoringMultimodal analgesia and site specific analgesiaPhysiotherapy and early ambulation
12Pain is the first enemy to mankind…. And anaesthesiologists aremankind’s guardian angels.
13The straw that breaks the camel’s back may be a very small one when the camel is nearing the end of it’s journey !
14Pre-operative concerns Associated injuriesCause for the fallDifficulty in assessing cardio respiratory reserveOsteoarthritis- Medications-NSAIDs
15Pre-operative concerns…. Pre-renal azotaemiaDVT prophylaxisDiabetes MellitusThe emotional significance of fracture to the geriatric patient must also be considered.
16Preoperative 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.
17Echocardiography 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.
18Prophylaxis 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 .
24Regional 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).
25The 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.
27General anesthesia -Pre-Oxygenation 8 deep breathsOxygen flow 10 L per min
28General anesthesia -Choice of Anesthetic agent Short acting and less lipid soluble drugsPropofolFentanylRocuroniumAtracuriumSevofluraneIsoflurane
29Intra-operative monitoring Pulse Oximetry5 lead ECG-ST analysisCapnographyNIBP- IBPTemperatureNeuromuscular monitoringUrine output
30Blood TransfusionProgressive reaming of femur and resection of the condyles is associated with steady blood loss
31Bone Cement- Hypotension The placement of the prosthesis involve the use of methylmethacrylate( bone cement )
32The cementing can cause hemodynamic fluctuations These fluctuations are related to the vasodilatory and mast-cell degranulating properties of the monomeric form of methylmethacrylate
33Bone Cement implantation 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.
34Bone Cement implantation syndrome - 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 perfusionTo improve ventricular contractility and function administer inotropes such as dobutamine.
35Fat embolismThe high incidence of fat embolism with femoral neck fracture repair and cemented endoprosthesis may contribute to pulmonary dysfunction
36Tourniquet in knee replacement Tourniquet inflation:may precipitate heart failuremay cause hypotension after release of tourniquetdue to:Release of acid productsAffected limb getting filled with bloodBlood loss
37Post-operative careImmediate postoperative care should be directed to supporting oxygenation, controlling pain, and facilitating the patient's return to the baseline mental status by emphasizing orientation.
39Postoperative 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.
40PRINCIPLES No.1: Start with low dose Avoid long acting drugs No.2: Use standing dose regimensNo.3: Repeated reassessment of pain reliefNo.4: Repeated reassessment of side effectsNo.5: Educate/inspire the care giver
41Post-operative concerns Post operative deliriumPost operative hypoxemiaHyponatremiaHypoglycemia
43ConclusionGeriatric 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.