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PROBLEMS DURING ORTHOPAEDIC SURGERY

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1 PROBLEMS DURING ORTHOPAEDIC SURGERY
Dr. M.J. MAHANTHESHA SHARMA M.D., D.A., PROFESSOR DEPARTMENT OF ANAESTHESIA J.J.M .MEDICAL COLLEGE DAVANGERE –

2 PROBLEMS DURING ORTHOPAEDIC SURGERY
Air way problems Positioning related problems Blood loss related problems Bradycardia / Asystole Paraplegia during scoliosis surgery Neuropraxia DVT problem Thromboembolism problems Fat embolism Bone cement related problems Anticoagulation therapy Tourniquet problems Postoperative 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 PROBLEMS Rheumatoid 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 airway Selection of regional technique Select fibroptic technique under light sedation. Careful positioning them for surgery. If GA is required use fibroptic bronchoscope. Check neurological functions Acute respiratory distress after extubation prevented by – Fibroptic intubation Kept 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 palsy Prone - 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 PROBLEMS Major Procedures likely to have estimated blood loss >1lt to 50% of blood volume Revision total hip arthroplasty Arthroplasty for congenital hip deformity Removal of infected prosthesis Revision IM nailing of a femur fracture Resection and reconstruction of bone lesions Bilateral total knee arthroplastis Biopsy of any sacral lesion Spinal fusion at more than three levels.

10 Hypotension Main complication of blood loss
Induced hypotensive technique Monitor intra op. SV and filling pressure. Homologous transfusion Intraoperative cell saver. Preoperative autologus blood donation. Invasive monitor – arterial pressure, CVP. Preoperative haematocrit value.

11 Treatment of hypotension
Maintain haematocrit level Volume replaced by Crystalloids Colloids Blood and blood products. Vesopressor Administration 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 vigilance Maintain adequate – blood volume with IV fluids Prophylactic 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 disease Malignant diseases Prolonged bed rest / immobilization General 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 PE Prompt diagnosis and therapy -  survival rate. Lower extremity # and surgeries.

19 Acute consequences of PE
Acute respiratory consequences : Increased alveolar dead space Pneumoconstriction Hypoxemia – V/Q mismatch Hyperventilation Haemodynamic consequences Increases the pulmonary vascular resistance. Increase the right ventricular after load. Severe increased RV after load leads to RV failure. Poor cardiopulmonary statushaemodynamic collapse.

20 Prevention Selection of regional anaesthesia
Early patient mobilization Use pneumatic compression stockings. Prophylactic drug therapy (most effective one) Low molecular weight heparin Warfarrin therapy Heparin blood level 0.2 – 0.4 U/ml Application of vascular filters Monitor PT & PTT screening in high risk patients.

21 Management Thrombolytic therapy Anticoagulant therapy IVC filters
Urokinase loading dose 250,000 U IV over 30 min. Maintenance dose infuse 100,000 U/h IV for 12-72hr. Streptokinase Loading dose 2000 U/kg IV over 10 min. Maintenance : 2000 U/kg/h IV for 24 hour. Anticoagulant therapy Warfarrin for 3-6 months Low 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/Morbidity The mortality rate is 10-20%. Patients with increased age Multiple underlying medical problems. Decreased physiologic reserve. History Trauma to long bone or pelvis - orthopedic procedures Parenteral lipid infusion Recent corticosteroid administration

23 Criteria for FES Major criteria Minor criteria Petechiae : conjunctiva, axilla PaO2 <8kPa (60mmHg), FiO2>0.4 CNS depression Pulmonary oedema Tachycardia > 110 Fever (Temp. >38.52°C) Emboli on fundoscopic examination Fat in urine Fat in sputum Unexpected anemia Increased sedimentation rate Unexpected thrombocytopenia Diagnose 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 reaming Use of fluted rods during TKR. Modify the reaming techniques Corticosteroids as prophylaxis for FES.

25 Management of FES Bronchoalveolar lavage (BAL) Supportive medical care
Adequate oxygenation and ventilation Hemodynamic support Blood products if indicated Hydration Prophylaxis for DVT Monitoring Continuous pulse oximetry monitoring Surgical care Reaming or nailing the marrow Prophylactic placement of IVC filters

26 Medical/Legal pitfalls
CT scan - to rule out intracranial pathology. Search for infectious agents Judicious fluid replacement is required. FES - altered mental status, fever, hypoxia. Rule out life threatening disorders Finally 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 epinephrine Prevents 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 Hg Lower limb 350 mm of hg Doppler occlusion pressure (DOP) : Upper limb DOP + 50 mm of Hg Lower limb DOP + 75 mm of Hg Above the DOPR. Upper limb 135 to 255 mm of Hg Lower 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 cm 15 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 Syndrome Intra operative Bleeding Pressure Sores and Chemical Burns Digital Necrosis Toxic Reactions Thrombosis Tourniquet pain Other 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 evaluation Time < 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 reactions IVRA – deflation, under inflation, faulty, sudden release  LA  circulation. Symptoms – immediate – CNS & heart. Prevention : Test the tourniquet Allergic 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.

41 Digital necrosis : Prolonged, constrictive, excessive/uncontrolled pressure. Results ischemia/anoxia  gangrene. Avoid, pressure drain, rubber/glove band. Thromboses : DVT, PE, lower extremity surgery. PE – tourniquet related cardiac arrest. Prevent dislodgement, subtherapeutic heperinization. Avoid elastic bandage for exsangunation.

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 anaesthesia Management is difficult Use 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 REFERENCES Seminars 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.

46 THANK YOU


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