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David Hirsch M.D. “There is a fracture, I need to fix it.” (http://www.yout ube.com/watch?v =3rTsvb2ef5k)

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Presentation on theme: "David Hirsch M.D. “There is a fracture, I need to fix it.” (http://www.yout ube.com/watch?v =3rTsvb2ef5k)"— Presentation transcript:

1 David Hirsch M.D. “There is a fracture, I need to fix it.” (http://www.yout ube.com/watch?v =3rTsvb2ef5k)

2  none

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

4  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  Anesthetic Strategy  Maximize Fi02  Eu-volemia (monitor CVP)  Vent hole in distal femur to decrease pressure  High pressure lavage to remove debris

6  Help create bloodless field  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  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  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  Symptoms  Coagulation Abnormalities  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

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12  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  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 12-24 hours of LMWH

14  Pre-op  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  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  Intra-op  Lateral Decubitus  +/ - Arterial Monitoring  Considerations  Bone Cement Implantation Syndrome  Blood Loss  Thromboembolism  Most often during insertion of femoral prosthesis

17  Bilateral  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 Arthroscopy  Knee Replacement

19  Pre-op considerations  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  Regional: 3 options  Femoral with or without sciatic block  Psoas Compartment Block  Local Infiltration

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22  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  Shoulder  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  Open or Arthoscopic  Infra-clavicular block preferred

24  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 15-16 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

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26  Most common  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 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  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  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; 2013. http://www.accessmedicine.com/content.aspx?aI D=57236471. Accessed June 12, 2013.  Chelly, Jacques. Peripheral Nerve Blocks: A Color Atlas. 2009.  Miller, Ronald D. and Manuel C. Pardo. Basics of Anesthesia, Sixth Edition. Chapter 32, 499-513 Copyright © 2011,


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