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Anesthesia for Orthopedic Surgery

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Presentation on theme: "Anesthesia for Orthopedic Surgery"— Presentation transcript:

1 Anesthesia for Orthopedic Surgery
David Hirsch M.D. “There is a fracture, I need to fix it.” (

2 Disclosures none

3 Topics Special considerations Hip Surgery Knee Surgery Upper Extremity
Spine Surgery Peripheral Nerve Blocks

4 Special considerations
Bone cement (polymethylmethacrylate) Binds prosthetic device to patient’s bone Can cause embolization of fat, bone marrow, cement and air into femoral venous channels Most frequently with femoral prosthesis Bone Cement Implantation Syndrome Hypoxia – increased pulmonary shunt Hypotension Dysrhythmias- heart block and sinus arrest Pulmonary hypertension – increased PVR Decreased cardiac output

5 Bone Cement Anesthetic Strategy Maximize Fi02 Eu-volemia (monitor CVP)
Vent hole in distal femur to decrease pressure High pressure lavage to remove debris

6 Tourniquet Help create bloodless field Goal < 2 hours
Can cause pain, metabolic alterations, hemodynamic changes Increase in blood flow in central circulation Pain severe enough to require substantial supplementation despite regional block Goal < 2 hours Can cause transient muscle dysfunction Permanent peripheral nerve damage Rhabdomyolysis Lower Extremity Can lead to DVT Sickle Cell Pay attention to maintaining normocarbia, hydration, normothemria

7 Tourniquet Deflation Fall in CVP, ABP Pulse increase Temp Decrease
Increased PaC02,EtC02, lactate and potassium from ischemic limb Cause increase in Minute Ventilation Rare-dysrhythmias Re-oxygenation Can worsen ischemic injury due to formation of lipid peroxides

8 Emboli Fat Embolism Syndrome 10-20% mortality
Within 72 hours following long-bone or pelvic fx Triad of dyspnea, confusion and petechiae 1)Fat globules released by disruption in bone enter circulation through tears in medullary vessels 2) or chylomicrons resulting from aggregation of circulating free fatty acids

9 Embolism Symptoms Treatment: Coagulation Abnormalities Pulmonary
Thrombocytopenia, increased clotting time Pulmonary Range from Mild hypoxia to ARDS Under GA Decline in ETCO2, arterial oxygen saturation Increase in PAP ECG-ischemic ST changes and right sided heart strain Treatment: Prophylactic: early stabilization of fracture Supportive: 02, with CPAP, high dose corticosteroid

10 Fat Embolism

11 Fat Emboli

12 DVT/PE Increased risk DVT/PE Higher risk
Obesity, age > 60, procedure > 30 min, tourniquet, LE fracture and immobilization > 4 days Older studies: PE as high as 20% with 1-3% fatal PE Anticoagulation as soon as possible Improvement in occurrence rate prophylaxis early rehab regional anesthesia?

13 DVT/PE Neuraxial Anesthesia
Alone or with general can reduce embolic complications Sympathectomy induced increase in LE venous blood flow Systemic anti-inflammatory effect of local anesthetic Decreased platelet reactivity Increase in factor 8,vW Decrease in Antithrombin III Decrease in stress hormone release Contraindicated with full anticoagulation therapy Generally not done within 6-8 hour prophylactic heparin dose or hours of LMWH

14 Hip Surgery Pre-op General vs. regional Spinal Mostly elderly
Pre-op hypoxia Fat emboli, bibasilar atelectasis, pulmonary congestion/effusion or infection General vs. regional Lower mortality early post-op period for regional After 2 months, no difference in mortality Spinal Hypobaric technique allows easier positioning

15 Total Hip Arthoplasty Etiology Osteoarthritis: repetitive trauma
Rheumatoid Arthritis Atlanto-axial instability: Preoperative: Flexion and extension radiographs of the cervical spine: Especially those on immune therapy, steroids methotrexate Intubate with fiberoptic/video assist Limited jaw mobility

16 Total Hip Replacement Intra-op Lateral Decubitus
+/ - Arterial Monitoring Considerations Bone Cement Implantation Syndrome Blood Loss Thromboembolism Most often during insertion of femoral prosthesis

17 Total Hip Arthoplasty Bilateral Revision
Recommended to monitor PA pressure in case of emboli PAP> 200 during first hip, contralateral should be postponed Revision Significant blood loss If possible, controlled hypotension

18 Knee Surgery Knee Arthroscopy Knee Replacement

19 Knee Arthroscopy Pre-op considerations Intra-op Management
Usually young/healthy however increasing frequency in elderly Intra-op Management Surgeons favor bloodless field (tourniquet) LMA Neuraxial vs. alternative regional Post-op Pain Control Multi-orifice catheter (Painball) Corticosteroid injection

20 Knee Surgery: Regional
Regional: 3 options Femoral with or without sciatic block Psoas Compartment Block Local Infiltration

21 Psoas Compartment Block

22 Total Knee Replacement
Pre-op Usually secondary to OA/RA Intra-op Blood loss decreased by tourniquet Bone cement implantation syndrome less likely then hip Regional technique similar to Arthroscopy Continuous catheter (Epidural vs. femoral)

23 Upper Extremity Shoulder Elbow Open or Arthoscopic
Lateral Decubitus or Beach Chair Interscalene block preferred +/- interscalene catheter Side effects: Phrenic nerve palsy Horner's syndrome Mild controlled hypotension requested Elbow Infra-clavicular block preferred

24 Beach-Chair Position Head and Upper torso elevated 30-90 degrees
Complications Stroke, Ischemic Brain Injury and Vegetative State Decreased cerebral Perfusion Each cm of head elevation above heart there is a decrease in arterial blood pressure of .77 20 cm not uncommon Approximately mm Hg gradient from heart/cuff Measure height difference at External Auditory Meatus Same level of Circle of Willis Avoid in Elderly, HTN Compromised autoregulatory curve


26 Spinal Surgery Most common Anesthetic Considerations
Posterior spinal fusion Scoliosis correction Combined antero-posterior procedures Anesthetic Considerations Neuro-monitoring Awareness (+/- BIS) Position Often prone for long periods of time Mayfield tongs or Prone Pillow Blood Loss

27 Post-Operative Vision Loss
Cases > 6 hour with > 1 L blood loss highest risk Ischemic Optic Neuropathy Variation in blood supply Orbital Edema Increased venous pressure can cause decreased arterial flow Ocular Perfusion Pressure Function of MAP and IOP (Intraocular Pressure) OPP = MAP – IOP Prone position associated with increased IOP Central Retinal Artery Occlusion Emboli Direct pressure on Eyeball

28 Post-Operative Vision Loss
Visual loss Registry with ASA Most Healthy/Prone position 93 total 83 Ischemic Optic Neuropathy 10 Central Retinal Artery Occlusion 55 bilateral Mean blood loss 2 L Range .1 – 25 L Blood loss > 1L and case longer then 6 hour = 96%

29 References Butterworth IV JF, Mackey DC, Wasnick JD. Chapter 38. Anesthesia for Orthopedic Surgery. In: Butterworth IV JF, Mackey DC, Wasnick JD, eds. Morgan & Mikhail's Clinical Anesthesiology. 5th ed. New York: McGraw-Hill; Accessed June 12, 2013. Chelly, Jacques. Peripheral Nerve Blocks: A Color Atlas Miller, Ronald D. and Manuel C. Pardo. Basics of Anesthesia , Sixth Edition.Chapter 32 , Copyright © 2011,

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