Presentation on theme: "PROBLEMS DURING ORTHOPAEDIC SURGERY"— Presentation transcript:
1 PROBLEMS DURING ORTHOPAEDIC SURGERY Dr. M.J. MAHANTHESHA SHARMAM.D., D.A.,PROFESSORDEPARTMENT OF ANAESTHESIAJ.J.M .MEDICAL COLLEGEDAVANGERE –
2 PROBLEMS DURING ORTHOPAEDIC SURGERY Air way problemsPositioning related problemsBlood loss related problemsBradycardia / AsystoleParaplegia during scoliosis surgeryNeuropraxiaDVT problemThromboembolism problemsFat embolismBone cement related problemsAnticoagulation therapyTourniquet problemsPostoperative delirium and confusion
3 AIRWAY PROBLEMS Complex airway challenges are common Juvenile rheumatoid arthritis, ankylosing spondylitis, prior cervical fusion.Impossible to intubate with conventional laryngoscopy.Failed intubation, trauma to airway, respiratory distress after extubation.
4 PROBLEMSRheumatoid arthritis C1-2 subluxation – instability Uncontrolled flexion – compromise the spinal cord.Uncontrolled flexion during spinal surgery-quadriplegia.Athletic patients coming for sport related surgery- Acute respiratory distress after extubation.- Low pressure pulmonary edema.Cricoarytenoid joints – decreases the glottic area.Intrinsic and extrinsic airway diseases - PFT.
5 PREVENTION &MANAGEMENT Careful assessment of the airwaySelection of regional techniqueSelect fibroptic technique under light sedation.Careful positioning them for surgery.If GA is required use fibroptic bronchoscope.Check neurological functionsAcute respiratory distress after extubation prevented by –Fibroptic intubationKept intubated 4-5 hours, head elevation 30°.Use smaller endotracheal tubes.
6 POSITION RELATED PROBLEMS Requires different intraoperative positions.Limbs are placed in unphysiological positions.Pressure sores – pressure effect.Nerve injury - compression or stretch.Ischaemia – vascular kink or obstruction.Ischaemia or compartment syndrome results.Avoid active movement of Ankylosed joint.
7 SPECIFIC PROBLEMS DUE TO POSITIONING THR (dependent limb) – compartment syndrome.Spinal surgery - prone - Brachial plexus palsyProne - compression - femoral or lateral cutaneous nerves.Prone – compression of eye – Post op. blindness.Brachial plexus stretch – Palsy - shoulder arthroplasty.
8 PREVENTION Correct positioning, proper padding. Avoid compression on eye.Avoid unnecessary stretching of the limbs.Avoid tight bandages and cast.Care of abduction braces after shoulder surgery.
9 BLOOD LOSS PROBLEMSMajor Procedures likely to have estimated blood loss >1lt to 50% of blood volumeRevision total hip arthroplastyArthroplasty for congenital hip deformityRemoval of infected prosthesisRevision IM nailing of a femur fractureResection and reconstruction of bone lesionsBilateral total knee arthroplastisBiopsy of any sacral lesionSpinal fusion at more than three levels.
10 Hypotension Main complication of blood loss Induced hypotensive techniqueMonitor intra op. SV and filling pressure.Homologous transfusionIntraoperative cell saver.Preoperative autologus blood donation.Invasive monitor – arterial pressure, CVP.Preoperative haematocrit value.
11 Treatment of hypotension Maintain haematocrit levelVolume replaced byCrystalloidsColloidsBlood and blood products.VesopressorAdministration of fluids by CVP.Don’t overload in high risk patients.
12 Bradycardia/ Asystole GA with vacuoronium / fentanyl combination.Regional – severe acute bradycardia.Common life threatening during regional.Block above T4 decrease heart rate.Needs beta agonists or atropine.Bezold-Jarisch type of reflex even below T6 block.Vagal mediated leads to asystole.Triggered by reduction in intrathoracic volume.Shoulder surgery - sitting - venous pooling volume.
13 Management Rapid treatment is required. Some times death or permanent brain damage.Proper vigilanceMaintain adequate – blood volume with IV fluidsProphylactic administration of atropine, beta agonists.Treat with epidrine 10-20mg, atropine 0.4 – 0.8 mg.Asystole treated by epinephrine, chest compression,
14 Paraplegia and scoliosis surgery Tragedy, uncommon in uncomplicated cases.Congenital scoliosis and more severe thoracic curves.Spinal cord function monitor - SSEP and wakeup test.Hypotensive anaesthesia with MAP 60 mm of Hg.Facilitate optimal blood flow to spinal cord.Stable blood volume with CVP and urine output.Avoid massive blood loss.Care during spinal distraction.Maintain stable circulation.Invasive monitoring as and required.Blood transfusion as and required.
15 Neuropraxia Postoperative nerve injuries are common. Neuropathy, surgical injury, malpositioning or tourniquet.Prevention :Avoid malpositioning, tight bandages or casts.Avoid compartment syndrome.Perioperative neuropraxia - anaesthesiologists concern.Legally shared the responsibility with surgeon.Medico legal problems are common.Preoperative nerve function assessment documented.
16 DVT PROBLEMS Complications of lower extremity surgeries. Fatal PE is 1-2% without thrombosis prophylaxis.Major trauma 58% of DVT, 15% proximal veins.With prophylaxis – DVT reduced to 20%.Fatal PE almost minimal or eliminated.15% of all postoperative deaths due to PE.
17 Thromboembolism Hip and knee surgeries Advanced age and Female sex Previous history of thromboembolic diseaseMalignant diseasesProlonged bed rest / immobilizationGeneral anaesthesia increased incidence.Surgical or accidental trauma.Fracture of femur and tibia high risk.
18 Pulmonary embolism PE is not a disease, complication of DVT. Ken Moser – substantial and unacceptable.Lethal condition, diagnosis missed.Non specific symptoms and signs.Untreated – die from future embolic episodes.Most of them die in first few hours.80% death due to massive PEPrompt diagnosis and therapy - survival rate.Lower extremity # and surgeries.
19 Acute consequences of PE Acute respiratory consequences :Increased alveolar dead spacePneumoconstrictionHypoxemia – V/Q mismatchHyperventilationHaemodynamic consequencesIncreases the pulmonary vascular resistance.Increase the right ventricular after load.Severe increased RV after load leads to RV failure.Poor cardiopulmonary statushaemodynamic collapse.
20 Prevention Selection of regional anaesthesia Early patient mobilizationUse pneumatic compression stockings.Prophylactic drug therapy (most effective one)Low molecular weight heparinWarfarrin therapyHeparin blood level 0.2 – 0.4 U/mlApplication of vascular filtersMonitor PT & PTT screening in high risk patients.
21 Management Thrombolytic therapy Anticoagulant therapy IVC filters Urokinaseloading dose 250,000 U IV over 30 min.Maintenance dose infuse 100,000 U/h IV for 12-72hr.StreptokinaseLoading dose 2000 U/kg IV over 10 min.Maintenance : 2000 U/kg/h IV for 24 hour.Anticoagulant therapyWarfarrin for 3-6 monthsLow molecular weight heparin.IVC filters
22 FAT EMBOLISM Frequency : Frequency is estimated to be 3-4%. Clinical diagnosis.Miss diagnosis due to subclinical illness.Mortality/MorbidityThe mortality rate is 10-20%.Patients with increased ageMultiple underlying medical problems.Decreased physiologic reserve.HistoryTrauma to long bone or pelvis - orthopedic proceduresParenteral lipid infusionRecent corticosteroid administration
23 Criteria for FESMajor criteriaMinor criteriaPetechiae : conjunctiva, axillaPaO2 <8kPa (60mmHg),FiO2>0.4CNS depressionPulmonary oedemaTachycardia > 110Fever (Temp. >38.52°C)Emboli on fundoscopic examinationFat in urineFat in sputumUnexpected anemiaIncreased sedimentation rateUnexpected thrombocytopeniaDiagnose FES : 1 major + 4 minor + fat microglobulinemia.
24 Prevention of FES Early rapid stabilization of fractures. Correction of hypovolemia.Drilling a small hole in the distal bone to vent fat.Use of an uncemented prosthesis for THR.Lavage of canal after each reamingUse of fluted rods during TKR.Modify the reaming techniquesCorticosteroids as prophylaxis for FES.
25 Management of FES Bronchoalveolar lavage (BAL) Supportive medical care Adequate oxygenation and ventilationHemodynamic supportBlood products if indicatedHydrationProphylaxis for DVTMonitoringContinuous pulse oximetry monitoringSurgical careReaming or nailing the marrowProphylactic placement of IVC filters
26 Medical/Legal pitfalls CT scan - to rule out intracranial pathology.Search for infectious agentsJudicious fluid replacement is required.FES - altered mental status, fever, hypoxia.Rule out life threatening disordersFinally diagnose FES.
27 BONE CEMENT PROBLEMS Acute hypotension is common during THR. Sometimes intraoperative death also.Earlier due to toxic effects of methyl methacrylate.Acute hypotension - acute RVF from PE or FE.Insertion of long stem cemented femoral component.Common with long stem cemented revision THR.Treat with 10-50µg epinephrinePrevents outlet obstruction and cardiac arrest.Due to modern technique acute hypotension is less.
28 ANTICOAGULATION PROBLEMS Receives drugs for prophylaxis against DVT/PE.Aspirin and NSIDS – inhibits platelets function.Warfarin therapy more complex.Estimation of prothrombin time or INR is must.If PT >2 seconds regional is not safe.LMWHS epidural haematoma.During insertion catheter & during postop. analgesia.First RA – remove catheter – start LMWHS.
29 TOURNIQUET Bloodless surgical field Risk of pressure related problems. Respond unfavourable to pneumatic.Anesthetist responsibility :Adequate preoperative assessment.Proper size, properly fit.Accurate, effective pressure.Systolic blood pressure and cuff pressure.Inform surgeon tourniquet time.
30 Tourniquet pressure Tourniquet pressure : 50 – 100 mm of Hg above the systolic blood pressure.Upper limb 250 mm of HgLower limb 350 mm of hgDoppler occlusion pressure (DOP) :Upper limb DOP + 50 mm of HgLower limb DOP + 75 mm of Hg Above the DOPR.Upper limb 135 to 255 mm of HgLower limb 175 to 305 mm of Hg
31 Specification of Tourniquet Tourniquet time :Initial time 90 minutes ideal is 45 – 60 minutes.>2 hours deflate for 5 minutes for reperfusion.Width of the cuff :Standard is 8.5 cm15 cm conical shaped produces subsystolic pressure required to stop detectable flow.Ischaemic time information to surgeons :First 2 hours – half hourly intervals.Next at 2.5 hours.Next every 15 minutes interval thereafter.
32 Tourniquet problems Nerve Injury Post - Tourniquet Syndrome Compartment Pressure SyndromeIntra operative BleedingPressure Sores and Chemical BurnsDigital NecrosisToxic ReactionsThrombosisTourniquet painOther Complications
33 NERVE INJURY Upper extremity, radial nerve. Transient to irreversible loss of function.Irreversible Tourniquet paralysis syndrome.Loss of sensory and motor function.Causes :Excessive, insufficient pressure.Mechanical stress ischemia or anoxia (N)Slow or cessation of sensory or motor conduction.
34 PREVENTIVE MEASURES Tourniquets use only recommended time. Check accuracy of the pressure.Do not use faulty pressure gauge.Effective pressure to achieve limb occlusion pressure.Use a cuff that properly fits the extremity.Apply the cuff to the limb with care and attention.Apply the cuff at the proper location on the limb.Don’t apply over the peroneal nerve or ulnar nerve.Avoid tourniquet to slip or twist - limb manipulation.Do not pinch or kink the connecting tubing.
35 POST TOURNIQUET SYNDROME Postischemic reactive hyperemia.To restore normal acid base balance in tissue.Prolonged bleeding from surgical wound.Edema, stiffness, pallor, weakness, paralysis.CAUSES :Prolonged ischemia neuromuscular injury.Under pressurized cuff.Calcified vessels – elderly, R.A. with steroids.
36 Preventive measures Good preoperative history & assessment. History of steroids, aspirin & oral contraceptives.History of hypertension.Coagulation profile.History of thromboembolic occurrences.Evidence of arterial calcification.Strict with the recommended tourniquet time limit.Use arterial occlusion pressure than systolic BP.
37 Compartment syndrome Relative complication of tourniquet. External and internal pressures - pain.Tense skin, swelling, weakness, parasthesia.Absent pulse – irriversible paralysis.Causes & prevention :Trauma or surgery, time, pH. capillary permeability, Prolongation of clotting.Preoperative evaluationTime < 90 minutes.
38 Intraoperative bleeding Causes :An under pressurized cuff.Insufficient exsanguinations.Avoid too slow inflation and deflation.Improper selection of cuff.Excessive padding.A cuff that is applied too loosely.Preventive measures :Select the proper style and size of tourniquet cuff.Good exsanguinations, some times re-exsanguinations.Consider to Re-inflation higher pressure.
39 Toxic reactionsIVRA – deflation, under inflation, faulty, sudden release LA circulation.Symptoms – immediate – CNS & heart.Prevention :Test the tourniquetAllergic history, CVS, CNS, Vascular problems.Dual bladder cuff, limb occlusion pressure.Intermittent deflation and reinflation.Observe the patient’s phsyiological status.
40 Pressure sores and chemical burns Less with pneumatic, pressure / time or both.Sensitive skin of children, discomfort to the patient.Chemicals, fluid accumulation under the cuff.Causes & Prevention :Inadequate padding or faulty cuff.Loose, thin or flabby skin.Skin breakdown, friction, or soft tissue folding.Leak under the cuff, position of the cuff.Correct limb protection technique.Do not readjust by rotation damage the tissues.
42 OTHER PROBLEMS Tourniquet pain : Thermal Damage to Tissues. Dull aching, some times severe pain, HTN.After deflation – reperfusion – different pain.Pain tolerance after inflation of cuff – 30 min unsedate.Thermal Damage to Tissues.Hyperthermia.Rhabdomyolysis.Metabolic Changes
43 POST OPERATIVE DELIRIUM / CONFUSION Postoperative cognitive function disturbance - delirium.Confusion state 12 to 72 hrs postop. restore 2-5 days.Elderly with preoperative cognitive function disturbance.History of Parkinson’s disease and alcohol intake.Delirium bilateral one stage TKR.This is not related to type of anaesthesiaManagement is difficultUse sedatives, Acetaminophen.
44 SUMMARY & CONCLUSION Unusual occasional and sometime fatal problems. Prevented by proper preoperative evaluation, selection of best anaesthetic technique suitable for the patient and particular type of surgery.This reduces incidence of morbidity and mortality.Whenever require institute intensive management to prevent death from fatal problems.
45 REFERENCESSeminars in Anaesthesia : Complication in Anaesthesia II. Vol.15, No.3, September 1996,e-medicine Nov.9, 2007.Miller’s Anesthesia – 6th Ed.,Internal Practice of Anaesthesia – 2nd Ed., Vol.2; 114/1 to 10.SOA text book dtp publishing company 2006.John L. Atlee. Complications in Anaesthesia. 2nd Ed., 2007.Robert R. Kirby. Clinical Anaesthesia practice Chapter 71,J.A. McEwen December 2007.Wylie and Churchill Davidson’s. A practice of anaesthesia. 7th Ed., , 707 to 718.Bulger CM, Jacos C, Patel NH. Epidemiology of acute deep vein thrombosis. Tech Vasc Interv Radiol Jun 2004;7(2):50-4.Deitelzweig S, Jaff MR. Meical management of venous thromboembolic disease. Tech Vasc Interv Radiol. Jun 2004;7(2):63-7.Katz DS, Hon M. Current DVT imaging. Tech Vasc Interv Radiol. Jun 2004;7(2):55-62.Levine M, Gent M, Hirsh J, et al. A comparison of low-molecular weight. Jun 2, 2006.
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