Total knee replacement (TKR) and hip fracture coming for replacement are the two most common surgical procedures after the sixth decade of life. Total knee replacement (TKR) and hip fracture coming for replacement are the two most common surgical procedures after the sixth decade of life.
Most of the patients have degenerative joint disease, commonly osteoarthritis (OA). Most of the patients have degenerative joint disease, commonly osteoarthritis (OA).
Other conditions requiring knee or hip replacement are injury to the neck of femur or knee joint, knee deformity, rheumatoid arthritis and gout. Other conditions requiring knee or hip replacement are injury to the neck of femur or knee joint, knee deformity, rheumatoid arthritis and gout.
Joint replacement is performed to relieve pain and morbidity. Joint replacement is performed to relieve pain and morbidity.
The challenge…. Decreased organ function and reserve Decreased organ function and reserve Co-morbid conditions Co-morbid conditions Consequences of polypharmacy Consequences of polypharmacy
Challenges have been converted into good outcomes… Better understanding on pathophysiology of aging Better understanding on pathophysiology of aging Better pharmacotherapy Better pharmacotherapy Safer anaesthetic techniques Safer anaesthetic techniques Improvements in monitoring Improvements in monitoring Multimodal analgesia and site specific analgesia Multimodal analgesia and site specific analgesia Physiotherapy and early ambulation Physiotherapy and early ambulation
Pain is the first enemy to mankind…. And anaesthesiologists are mankinds guardian angels.
The straw that breaks the camels back may be a very small one when the camel is nearing the end of its journey !
Pre-operative concerns Associated injuries Associated injuries Cause for the fall Cause for the fall Difficulty in assessing cardio respiratory reserve Difficulty in assessing cardio respiratory reserve Osteoarthritis- Medications-NSAIDs Osteoarthritis- Medications-NSAIDs
Pre-operative concerns…. Pre-renal azotaemia Pre-renal azotaemia DVT prophylaxis DVT prophylaxis Diabetes Mellitus Diabetes Mellitus The emotional significance of fracture to the geriatric patient must also be considered. The emotional significance of fracture to the geriatric patient 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.
Echocardiography 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 concerns Regional General anesthesia
The choice of anaesthesia is determined by: i) surgical factors ii) Patients factors iii) Estimates of risk associated with anaesthesia techniques
Regional Anesthesia - Advantages Stress response to surgery Stress response to surgery Intraoperative blood loss Intraoperative blood loss Post-operative hypoxia Post-operative hypoxia PONV PONV DVT- early mobilization DVT- early mobilization
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 -Pre-operative beta blockade CAD CAD Hypertension Hypertension Diabetes mellitus Diabetes mellitus Hypercholesterolemia Hypercholesterolemia Renal dysfunction Renal dysfunction Goal: Heart rate between 60-70. Goal: Heart rate between 60-70.
General anesthesia -Pre-Oxygenation 100% Oxygen 100% Oxygen 8 deep breaths 8 deep breaths Oxygen flow 10 L per min Oxygen flow 10 L per min
General anesthesia -Choice of Anesthetic agent Short acting and less lipid soluble drugs Propofol Propofol Fentanyl Fentanyl Rocuronium Rocuronium Atracurium Atracurium Sevoflurane Sevoflurane Isoflurane Isoflurane
Intra-operative monitoring Pulse Oximetry Pulse Oximetry 5 lead ECG-ST analysis 5 lead ECG-ST analysis Capnography Capnography NIBP- IBP NIBP- IBP Temperature Temperature Neuromuscular monitoring Neuromuscular monitoring Urine output Urine output
Blood Transfusion Progressive reaming of femur and resection of the condyles is associated with steady blood loss
Bone Cement- Hypotension 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 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.
Bone 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 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 replacement Tourniquet inflation: i) i) may precipitate heart failure ii) ii) may cause hypotension after release of tourniquet due to: a) a) Release of acid products b) b) Affected limb getting filled with blood c) c) 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
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 dose Avoid 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 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.