Anesthesia for Major Orthopedic Surgery

1. Anesthesia for Major Orthopedic Surgery R3 이 재 우

2. Rheumatoid Arthritis • Total joint replacement • Total Knee replacement • The Patientswith a Hip Fracture • Anesthetic Technique • Scoliosis and Spinal Surgery • Regional Blocks

3. Rheumatoid Arthritis

4. Generalized chronic inflammatory disease • Genetic-asso. With HLA DR4

5. Asso. with T-cell immune response • Recent also infection

10. Most significant to anesthesiologist • changes that affect the airway • Tracheal intubation • Maybe difficult • Fiberoptic intubation

11. Affectings the airway • Hypoplastic mandible • Receding chin • T-M jt. Ankylosis • Cricoarytenoid arthritis • Destructive change in jt. & ligament structure of C-spine

12. Three major anatomic alteration in the C-spine • subluxation

14. Subaxial subluxation • 15% displacement • Superior migration of the odontoid into the foramen magnum

15. Caution • Procedure performed under general anesthesia • Avoid an aggressive jaw thrust that may cause excess neck motion

16. Total joint replacement

17. Providing on infection-free environment • Adequate monitoring • ECG II & modified V5 • Pulse oximetry • During long bone reaming & jt. Cementing • ETCO2 • Detect episode of fat and pul. Emboli • Arterial or central line(if necessary) • Urinary catheter(controversial) • Position時 careful !!!

18. T.H.R. ( I ) • Spinal, epidural, GA may be used • Spinal & epidural Ane. • Drier surgical field with lower blood loss than GA • Decrease the incidence of deep vein thrombosis and thromboembolism ⇒ preferred techniques !!!

19. T.H.R. ( II ) • Induced hypotension • Decreased blood loss • Diminish allogenic transfusion • Provide a dry surgical field & a dry cement-bone interface ⇒ 1970s ∼ 1980s

20. T.H.R. ( III ) • Current methods • To avoid allogenic transfusion • Pre-surgical blood donation • Intra-op cell salvage • Post-op wound drainage devices • Acceptance of lower post-op Hct. ⇒ decrease the requirement for aggressive hypotensive techniques

21. Cementing ( I ) • Cause – methylmetacrylate monomer • Complication • Fat & bone marrow embolement • Thromboplastic element • Air emboli ⇒ the more liquid, the higher the incidence

22. Cementing ( II ) • Higher risk patients • Hypertensive history • Hypovolemia • Preexisting cardiovascular disease • Cementing時 • 100% supplemental oxygen should be administrated

23. Post-op T.H.R. • Intramuscular, intravenous PCA • Epidural narcotics ⇒ post-op pain relief ⇒ enhance rehabilitation

24. Total Knee replacement

25. Performed under tourniquet(TQ) • Intra-op pain • Manifest as heart rate ↑ & BP ↑ d/t A delta & C fiber firing • TQ release • May become hypotensive • Massive pulmonary embolism ↑ • Return of acidotic products • ETCO2 ↑ • Core temperature ↓

26. Spinal & epidural anesthesia • Excellent methods for TKR • Useful to administration narcotics and to infuse of local anesthetics via epidural catheter • GA • PCA → best alternative for post-op pain manage

27. The Patientswith a Hip Fracture

28. Predisposing factors • Lower limb dysfunction • Visual impairment leading to a fall • Previous stroke • Parkinson`s disease • Use of long-acting barbiturates • Increasing age • Psychotropic medication • Dementia • Osteoporosis • Cold climate

29. The Time of Operation • Preferable as soon as possible after hip fracture(in healthy patients) • Correctable pre-op medical condition or comorbidity ⇒ Delay !!

30. Proper Evaluation ( I ) • Important • Respiratory evaluation • Baseline PaO2– 70 mmHg range • PaO2 significantly ↓ • Pul. Embolism may be occurring from fat or deep v. thrombosis • Cardiovascular evaluation • In general, recent myocardial infarction : Trend toward earlier operation - Risk-benefit ratio of operation

31. Proper Evaluation ( II ) • Neurologic evaluation • Intravascular volume status • ∵ blood loss into the femur after fracture → result in significant hypovolemia • ∵diuretics medication pt. Pre-op →severe

32. Monitoring ( I ) • Same as the aboves • Low PaO2 level • Carefully pulse oximetry (especially, femur reaming & cement insertion) • Urinary catheter – should !!! • U.O. : valuable monitor of intravascular volume

33. Monitoring ( II ) • CHF patient • Significantly dehydrated state d/t • Blood loss into the fracture • Continued administration of diuretics • Attempt to keep pt. Fluid restricted • Central venous & pul. a. pressure monitor

34. Anesthetic Technique

35. Many physicians – regional : safer • Outcome studies • No differences • Motality, age, sex, type of fracture,Dementia • Determining anesthetic technique • Pt. Factor, duration of surgery, type of fracture → important role • Intertrochanteric Fx. • Blood loss ↑ • Surgical times ↑

37. Positioning & post-op concern • Positioning • Especially, perineal area • Post-op concern • Hypothermia • Neurovascular status • Pulmonary & cardiac state • Intravascular volume status

38. Scoliosis and Spinal Surgery

39. Regional Blocks

40. Provide • pre-op pain relief, anesthesia and analgesia • Intra-op, post-op pain relief • Choose the specific pph. N. block based on surgical site • Interscalene block- For shoulder surgery • Infraclavicular block- for surgery below elbow • Axillary block-for ulnar side of the hand

42. Success rate improve ← Nerve stimulator use