Anesthesia for Ortho

1. Anesthesia for
Orthopedics surgery
Moderator :
Assoc. Prof Dr. Sujita Manandhar
Assist. Prof Dr. Pawan Kumar Hamal
Presenter : Dr. Krishna Dhakal

2. Learning objectives
• Describe general considerations and goals related to orthopedic
surgery
• Describe specific consideration associated with orthopedic
surgery ,their anesthetic implications and management
• Describe briefly about special orthopedic condition and their
anesthetic concerns
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3. • General consideration
1. Perioperative Goals
a) Pre op considerations
b) Intraoperative Goals
c) Post operative considerations
2. Age specific orthopedic conditions
3. Medical comorbidities
4. Co existing medications
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4. • Specific considerations
1. Positioning
2. Bone cement Implantation syndrome
3. Pneumatic Tourniquets
4. Fat embolism
5. Deep vein thrombosis and thromboembolism
6. Regional anesthesia and anticoagulation
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5. • Pre op considerations
1. Age
2. Co morbidities
3. Medications
4. Diagnostic studies
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6. Pre op considerations
• 1.Age of the patients
• Elderly
• Medical Conditions(MI,COPD,HTN CVD,DM)
• Anticoagulation therapy
• Renal dysfunctions
• Airway difficulties
• Osteoporesis
• Pediatrics
• Congenital deformities
• Undiagnosed muscular dystrophies
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7. Pre-op considerations
2. Comorbidities
• Trauma- stabilization
• Geriatric populations- HTN,CAD,CVD,COPD, osteoarthritis, RA
• Obesity-HTN,CAD,DM
3. Medications
• Steroids
• Opiods
• Antihypertensives
• NSAIDS
• Immunotherapy-Methotrexate
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8. Pre-op considerations
• Radiologic studies
• C-xray
• Xray –C spine-AP, lateral
• Cardiac studies
• ECG
• Echocardiography
• Labs
• CBC
• Platelets
• Renal functions,electrolytes
• Coagulation studies-
Anticogulation
medications,immunetherapy
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9. Choice of Anesthetic Technique
• Regional anesthesia vs General anesthesia
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10. Choice Of Anesthesia Technique contd..
Many orthopedic surgery because of localized peripheral sites led
themselves to RA techniques
Advantages of RA
• No or minimal airway manipulation
• Improved postoperative analgesia
• Decreased incidence of PONV
• Less respiratory and cardiac depression
• Reduced blood loss
• Decrease risk of DVT/Thromboembolism
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11. Upper Extremity Surgery
RA (+/- GA)
1. IRVA(Intravenous Regional Anesthesia)
• Advantage: simplicity of technique, rapid onset of action, controllable
duration of action and rapid return of function.
• Disadvantage: continuous use of tourniquet, the potential toxic effect
of the drug and lack of postoperative analgesia.
2. Brachial Plexus Block
3. Blockade of peripheral nerves
• Radial Nerve block.
• Median Nerve block.
• Ulnar Nerve block.
• Digital Nerves.
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12. Lower Extremity Surgery
• Can be completely performed under regional anesthesia
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13. Regional anesthesia technique for surgery of the
lower extremity
1. Hip
2. Knee
3. Lower leg
4. Ankle
5. Foot
• Spinal, epidural, lumbar plexus block.
• Spinal,epidural,3 in 1 block, femoral
sciatic block.
• Spinal, epidural, sciatic block, femoral-
sciatic block, sciatic and saphenous
block.
• Spinal, sciatic block
• Spinal, sciatic, ankle block, trans
metatarsal block.
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14. Intraoperative Goals
• Surgical anesthesia
 To provide optimal surgical operating conditions
 Appropriate depth of anesthesia
 Adequate pain control
• Optimize surgical exposure
 Neuromuscular blockade in GA
 Neuraxial anesthesia
 Peripheral nerve block
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15. Intraoperative Goals
• Proper positioning to Prevent stretch/compression nerve
injuries
• Prevent significant blood loss
may be reduced through
• proper positioning
• intraoperative blood salvage,
• induced hypotension,
• intraoperative hemodilution, and
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16. Post operative considerations
• Postoperative pain management
• Peripheral nerve blockade with or without catheter
• Opioids for breakthrough pain/multimodal analgesia
• NSAIDs and adjuvant analgesic medications
• Others
• ICU/Post op care
• Mechanical ventilation: if needed
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17. Specific Considerations
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18. Positioning
• Why positioning important??
1. Patient safety
2. Prevent nerve injuries
3. Enable iv access, ET Tube , catheter to remain patent
4. Enable proper monitor
5. Facilitates surgical approach
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19. Positioning
• Supine
• Lateral
• Prone
• Beach chair
• Fracture table
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20. Positioning contd..
• Supine
• Patient on back
• Arms on arm boards
• Arm < 90 degrees
• Arm is supinated ( palm up)
• Place padding under elbow if
able
• Arm tucked
• Check fingers
• Check IV lines and SpO2
probe
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21. Positioning contd..
 Lateral
 Body alignment
 Keep neck in neutral position
 Always place axillary roll
 Place padding between knees
 Place padding below lateral aspect
of dependent leg
 Position arms to parallel to one
another
 Place padding between arms or
place non-dependent arm on
padded surface
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22. Positioning contd…
• Prone
• Face down
• Head placement
• Head straight forward
• ET tube placement and
patency
• Check bilateral eyes/ears
for pressure points
• Head turned
• Check dependent eye/ear,
ETT placement
• Be aware of potential
vascular occlusion
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23. Positioning contd..
• Prone
 Arm placement
 Tucked – similar to supine
 Abducted
▪ Check neck rotation and arm
extension to avoid brachial
plexus injury
▪ Elbow are padded
 Chest rolls
 Iliac support
 Padding in placed under iliac crests
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24. Positioning contd..
Beach Chair
• Arms- supported to prevent
stretching of the brachial
plexus.
• Elastic stockings and active leg
compression devices - help
maintain venous return.
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25. Positioning contd..
• Fracture chair
• Maintenance of traction on the
fractured extremity, allowing
• manipulation for closed reduction
and fixation, and
• access to the fracture site for
radiography in several planes
• The ipsilateral arm is positioned on
an arm board or sling without
stretching the brachial plexus
• Gentiles protection
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26. Bone Cement Implantation Syndrome
• Bone cement Syndrome
Characterised by hypoxia , hypotension or both and or unexpected
loss of consciousness occurring at the time of cementation,
prosthesis insertion ,reduction of joint or occasionally, limb
tourniquet deflation in a patient undergoing cemented bone
surgery
• Bone cement-
Methyl methacrylate(MMA) an acrylic bone cement used during
arthroplastic procedures.
Donaldson et al 2009
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28. •Clinical presentations
• Fever
• Hypoxia
• Hypotension
• Tachycardia
• Dysrhythmia
• Mental status change
• Dyspnea
• Decreased End tidal CO2
• Right ventricular failure and
cardiac arrest
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29. •Treatment strategies
1. Increasing FiO2 prior to cementing
2. Monitoring & maintaining hydration
3. Creating vent hole in the distal femur
4. High pressure lavage of femoral shaft to remove debris
5. Using cementless prosthesis
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31. Pneumatic tourniquet
• To create bloodless field
• Not > 2 hours
• Prolonged inflation (>2hrs) leads
to
-transient muscle dysfunction
- rhabdomyolysis,
-nerve injuries
• 100 mmHg above systolic blood
pressure
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32. Pneumatic tourniquet
• Advantage
• Eliminate intraoperative
bleeding
• Disadvantages
• Neurologic effect
• Muscle change
• Systemic effects of the
tourniquet inflation
• Systemic effects of the
tourniquet release
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33. Pneumatic tourniquet
•Problems with inflation
• Pain
• Sympathetic stimulation:
Marked HTN, tachycardia, and diaphoresis
• Arterial thromboembolism, pulmonary embolism
• If prolonged >2 hour
Transient muscle dysfunction  rhabdomyolysis, permanent
nerve damage
• Folds or lines under tourniquet may cause bruising or pressure
necrosis of skin
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34. • Problems with deflation
• The good: decreases the tourniquet pain experienced
• Disadvantages
• Increase in blood level of: PaCo2, lactate, potassium: d/t washout of
accumulated waste
• Increase. in MV of spontaneously breathing patients
• Transient metabolic acidosis
• Core temperature decreases
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35. Prevention
• Select patients
• Wide, low-pressure cuff
• Apply the lowest pressure to prevent bleeding
• Limit time to 2 hours
• Set maximum pressure
-Arm 50-75 mmHg above systolic
-Leg 75-100 mmHg above systolic
• Doppler guided tourniquet pressure inflation
• Adequate padding underneath
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36. Fat Embolism Syndrome
• A well known complication of skeletal trauma and surgery
involving femoral medullary canal
• A physiologic response to fat within systemic circulation
• FES <2 - 22% , all long bone fracture
• Mortality rate - 10-20 %
• Presents within 72 hrs. following fracture of long bone,pelvis
with triad of – Dyspnea, confusion, petechiae
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38. Clinical manifestations
• Neurologic: agitation, confusion,
stupor, coma
• Hematologic: thrombocytopenia,
prolonged CT
• Cutaneous: petechiae
(pathognomonic)
• Pulmonary: mild hypoxia, resp.
failure, ARDS (10%)
• CVS: persistent tachycardia,
hypotension
Dyspnea
Confusion Petechiae
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39. Gurd's Diagnosis of FES
• Major Features (at least one)
• Respiratory insufficiency: PaO2 <60
mm Hg, FiO2: 0.4
• Cerebral involvement: altered
mentation
• Petechial rash
• Minor Features (at least four)
• Pyrexia
• Tachycardia
• Retinal changes
• Jaundice
• Renal changes
• Laboratory Features
• Fat microglobulinemia
• Anemia
• Thrombocytopenia
• High ESR
Gurd AR, Wilson RI: The fat embolism syndrome. J Bone Joint Surg Br 56:408-416, 1974
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40. Schonfield index
• A score of >5 required for
the diagnosis of FES
Schonfeld SA, Ploysongsang Y, DiLisio R, et al: Fat embolism prophylaxis with corticosteroids: A prospective
study in high risk patients. Ann Int Med 99:438-443, 1983.
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41. How to diagnose FES under GA
• Decline in end tidal CO2
• Decline in arterial oxygen saturation
• Rise in pulmonary artery pressures
ECG
• Ischemic-appearing ST segment changes
• Right sided heart strain
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42. Treatment
Prophylactic
 Early stabilization of the fracture
Supportive
 Respiratory care
▪ O2 therapy (with CPAP ventilation - ARDS)
 Invasive monitoring
▪ Volume status, Inotrops
▪ Vasodilators for Pulmonary HTN
 High dose corticosteroid
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43. One of the leading causes of morbidity and mortality after
major orthopedic surgeries like THA, TKA, hip and pelvic
fracture surgeries.
• Incidence of DVT : 40-80% without prophylaxis
• Incidence pulmonary embolism is 20%(Fatality-1-3%)
• Major pathophysiological mechanism(Virchow’s Triad)
• Venous stasis
• Hypercoagulable state
• Endothelial damage
DVT And Thromboembolism
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44. DVT/Thromboembolism contd..
Risk Factors
• Obesity
• Age > 60 years
• Previous PE and DVT
• Cancer
• Procedure > 30 mins
• Use of tourniquet
• Lower extremities fracture
• Immobilization > 4 days
• Thrombophilia: mainly
hereditary eg. Factor V Leiden
(most common)
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45. Prevention
• Non-pharmacological
• Intermittent pneumatic compression
• TED stockings
• IVC filters: in patients C/I for anticoagulation
• Pharmacological
• Low dose heparin (UF)
• Warfarin
• LMWH
• Recent alternatives to:
• Fondaparinux
• Dabigatran
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46. •Treatment
• Anticoagulants OR Thrombolytics?
• Venous thrombi  Fibrin thrombi  anticoagulation for Prevention and treatment
• Severe, possibly fatal PE  Thrombolytics
WARFARIN
Blocking of Vit K dependent
coagulation factors
II, VII, IX, and X)
LMWH
inactivating thrombin and activated factor X
(factor Xa) through an antithrombin (AT)-
dependent mechanism
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47. Regional Anesthesia and anticoagulation
• Regional anesthesia and anticoagulation are important
considerations in orthopedic surgeries.
• A plan management for anticoagulant and anesthetic technique
must be taken for the specific patient under anticoagulation
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51. Anesthetic considerations
Rheumatoid arthritis
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52. Osteoarthritis
• Anesthetic concrens
• Reduced joint movement
• Airway management
• IV access
• Spinal or epidural - difficult
• Positioning
• Concurrent analgesic therapy
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53. Ankylosing spondylitis
• Ankylosing spondylitis involves ossification of the axial ligaments
progressing from the sacral lumbar region cranially,
• Significant loss of spinal mobility
• Regional anesthesia may be difficult
• Reduced movement of C-spine and TMJ
• Thoracic spine movement restriction
• Difficulty in positioning
• Others:
• Aortic insufficiency, cardiac conduction defects, and pleural effusions.
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54. Anesthesia for spinal surgery
•Pathological condition requiring spine surgery are
– Spinal cord compression
– Herniation of an intervertebral disk
– Spinal deformities (scoliosis)
– Tumor or infection
– Vascular malformation
– Post traumatic stabilization
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55. Preoperative assessment
•Airway evaluation
•Respiratory evaluation
•Cardiovascular evaluation
•Neurological evaluation
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56. Monitoring
•Standard monitoring:
•NIBP, SPO2, HR, ECG, Capnograph, temperature
•Special monitoring:
•Invasive blood pressure, central venous pressure and urine output
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57. Problems associated with prone position in
Spine Surgery
1. Chest pressure - decreased chest compliance and impaired
respiration.
2. Abdominal pressure -inferior vena cava compression -
retrograde venous flow into the vertebral venous plexus -
resulting in epidural venous engorgement.
3. Peripheral nerve damage - as a result of excessive pressure or
traction.
4. Eyes, ears, nose, breast, and genitalia must be protected from
excessive pressure
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59. Take home message
• Older age is a significant risk factor for poor outcome after
orthopedic surgery. They often have multiple comorbid
conditions that must be considered in the perioperative plan
• Proper positioning for orthopaedic procedures is paramount to
providing optimal surgical conditions, as well as avoiding
potential stretch and compression injuries.
• Fat embolism syndrome and bone cement implantation
syndrome - result in life threatening emergency thus
anticipation and management should be prompt
• Patients undergoing major orthopaedic are at high risk for
thromboembolic complications. Use of current pharmacologic
and mechanical methods of thromboprophylaxis is required
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60. Take home message
• Pneumatic tourniquets are often used to create a bloodless field but
also are associated with potential problems; hemodynamic changes,
pain, metabolic alterations, arterial thromboembolus, and even
pulmonary embolism
• Regional anaesthesia reduces perioperative complications compared
with GA, and may provide superior analgesia
• Regional anaesthesia and anticoagulation are important
considerations in orthopaedic surgeries. A plan management for
anticoagulant and anesthetic technique must be taken for the
specific patient under anticoagulation
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61. References
• Mikhail & Morgan’s Clinical Anesthesiology, 5th edition
• Barash, Paul G Cullen Clinical Anesthesia, 8th edition
• Ronald D. Miller Miller's Anesthesia , 7th edition
• American Society of Regional Anesthesia and Pain Medicine, Evidence-
Based Guidelines on regional anesthesia and anticoagulation,
3rd Edition
• Internet: www.asra.com/advisory-guidelines/article/4/interventional-
spine-and-pain-procedures-in-patients-on-antiplatelet-and-anticoa
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62. Thank You
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