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Anesthesia for Orthopedic surgery

Anesthesia for Orthopedic surgery. อรุณชัย นรเศรษฐกมล. Content. General consideration Age-specific orthopedic conditions Medical comorbidities Coexisting medication Specific consideration Positioning Bone cement Pneumatic tourniquet Fat embolism Deep vein thrombosis & Thromboembolism.

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Anesthesia for Orthopedic surgery

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  1. Anesthesia for Orthopedic surgery อรุณชัย นรเศรษฐกมล

  2. Content • General consideration • Age-specific orthopedic conditions • Medical comorbidities • Coexisting medication • Specific consideration • Positioning • Bone cement • Pneumatic tourniquet • Fat embolism • Deep vein thrombosis & Thromboembolism

  3. Age-specific orthopedic condition • Young adult • ACL reconstruction, Rotator cuff • Elderly • Hip, Knee arthroplasty • Hip Fracture • Children • Congenital orthopedic surgery

  4. Medical comorbidities • Elderly patients • Multiple organ dysfunction • Rheumatoid arthritis • Osteoarthritis • Ankylosing spondylitis

  5. Rheumatoid arthritis problem should be aware • Cervical spine instability • IV access • Systemic involvement • Airway management • Spinal or epidural may be difficult • Positioning

  6. Osteoarthritis

  7. Joint usually involved in Osteoarthritis

  8. Osteoarthritis ( OA)problem should be aware • Reduced joint movement • Airway management • IV access • Spinal or epidural may be difficult • Positioning • Concurrent analgesic therapy

  9. Ankylosing spondylitis

  10. Ankylosing spondylitis

  11. Ankylosing spondylitis (AS)problem should be aware • Fix flexion deformity • Regional anesthesia may be difficult • Abnormal spread of local anesthetics

  12. Coexisting medication • Antihypertensive drugs • Steroids • Aspirin • NSAIDs • Opioid analgesics • Immunosuppressive drugs

  13. Specific consideration

  14. Positioning • Supine • Lateral • Prone • Beach chair • Fracture table

  15. Why is positioning important? • Enable IV and catheter to remain patent • Enable monitors to function properly • Facilitates the surgeon’s approach • Patient safety

  16. Supine

  17. 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 SaO2 probe

  18. Lateral

  19. Lateral • Body alignment • Keep neck in neutral position • Always place axillary roll • Place padding between knees • Place padding below lateral aspect of dependent leg

  20. Lateral • Position arms to parallel to one another • Place padding between arms or place non-dependent arm on padded surface

  21. Prone

  22. 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

  23. 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

  24. Fracture table

  25. Injury occuring from prolonged positioning • Eye compression in prone position • Skin breakdown due to prolonged positioning

  26. Bone cement Polymethylmethacrylate: MMA

  27. Liquid MMA monomer + MMA powder intramedullary pressure high medullary content into circulation (fat, marrow, thrombus, air, bone cement) Embolization to the lung unbound MMA monomer Absorbing into the circution Vasodilation

  28. Bone cement implantation syndrome ( BCIS) • Release of vasoactive and myocardial depressant substances • Intravascular thrombin generation in the lungs • Direct vasoactive effects of absorbed MMA • Acute pulmonary microembolization

  29. Clinical presentation • Fever • Hypoxia • Hypotension • Tachycardia • Dysrhythmia • Mental status change • Dyspnea • End tidal CO2 decrease • Right ventricular failure and cardiac arrest

  30. Management • Supportive care • Monitoring vital signs • O2 supplement • IV fluid • Vasopressor

  31. Pneumatic tourniquet • No more than 2 hours • 100 mmHg above systolic blood pressure • 250 mmHg for arm • 350 mmHg for leg

  32. Pneumatic tourniquet • Advantage • Eliminate intraoperative bleeding • Disadvantages • Neurologic effect • Muscle change • Systemic effects of the tourniquet inflation • Syeyemic effects of the tourniquet release

  33. Neurologic effects • Tourniquet pain and hypertension If > 45-60 mins • Neurapraxia if > 2 hours • Nerve injury at the skin level the edge of the tourniquet

  34. Muscle changes • Cellular hypoxia • Cellular acidosis • Endothelial capillary leak • Limb becomes colder

  35. Systemic effect of tourniquet inflation • Arterial pressure elevated

  36. Systemic effect of tourniquet release • Transient fall in core temperature • Transient metabolic acidosis • Release of acid metabolites into central circulation • Transient fall in arterial pressure • Transient increase in EtCO2

  37. 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 • Adequate padding underneath

  38. Fat embolism • The mechanical theory • The biochemical theory

  39. Injury of the long bone, pelvis or surgery that increases intramedullary pressure Force large fat droplets into the systemic venous circulation Embolizing to the right heart and lung pulmonary hypertension

  40. Clinical finding • Cardiovascular • Persistent tachycardia, hypotension • Respiratory • Dyspnea hypoxia hemoptysis • Cerebral • Delirium stupor seizure coma • Ophthalmic • Retinal hemorrhage • Cutaneous • petechiae • Other • Jaundice fever

  41. Treatment • Prophylactic • Early stabilization of the fracture • Supportive • Respiratory care • Maximize O2, ventilation • Invasive monitor • Volume status • Inotrope • High dose corticosteroid

  42. Deep vein thrombosis & Thromboembolismlower extremities, pelvis • Major pathophysiological mechanism • Venous stasis • Hypercoagulable state • Endothelial damage

  43. Risk Factor • Obesity • Age > 60 years • Procedure > 30 mins • Use of tourniquet • Lower extremities fracture • Immobilization > 4 days

  44. Prevention • Prophylactic anticoagulant • Low dose heparin • Warfarin • LMWH • Intermittent pneumatic compression • Neuraxial anesthesia reduce thromboembolic complication

  45. Major orthopedic procedure • Total hip replacement • Fracture of the hip • Total knee replacement • Spinal surgery

  46. Hip surgery • Patient • Limit ability to exercise • Cardiovascular function can be difficult to assess • Elderly with systemic disease, OA,RA • Blood loss • Use of hypotensive technique or reginal anesthesia reduces blood loss

  47. Positioning • Mostly lateral decubitus position • Ventilation perfusion mismatch • Neurovascular problem

  48. Potentially life-threatening complication • Bone cement implantation syndrome • Intra and postoperative hemorrhage • Venous thromboembolism

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